UNITED STATES OF AMERICA
WASHINGTON,  D. C.
GPO  16—67244-1 
 
 
"Ad &AfcV^ ^-:4_i
r.
V#.  S-r^J-
#&

!yrr/y/r- SJ.LSs:aw
Ob»
%f
i
<. 
I
/ 
PATHOLOGICAL
PRACTICAL  RESEARCHES
DISEASES OF THE BRAIN
SPINAL  CORD.
&6*fau
     BY JOHN ABERCROMBIE, M. D.
FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH, ETC., AND FIRST
      PHYSICIAN TO. HIS MAJESTY IN SCOTLAND.


      ! SUBCfc'OtfGEMrSACStjFFlCt
!  •  tu, 2U uwi
SECOND AMERICAN, FRO
JVP THH THTTCD EBINBURGW
EDITION, ENLARGED,
      PHILADELPHIA:    >
CAREY, LEA AND BLANCHARD.
          1836. 
V >•

N
) Z3^
 
           PREFACE

                   TO

THE THIRD EDINBURGH  EDITION.
  In the third Edition, which, for the accommodation of stu-
dents, is printed in a small and portable form, a considerable
number of new facts and  observations have been added from
various sources.   The more important of the new matter, of
an original kind, will be found in cases 7, 26, 80, 85, 96, 121,
and 132.  In preparing this  Edition,  the  Author  has  also
availed  himself of many important observations, which have
been added, in the form of notes, to the French translation of
this volume,  by M.  Gendrin.   Whenever the  name of that
eminent individual occurs, the reader will understand that this
translation is referred to.
  Edinburgh, August, 1834. 
 
PREFACE.
  It is a matter of the utmost delicacy for a physician to ob-
trude upon the profession his  general statements, in  regard
either to the phenomena of disease, or the action of remedies.
The value of such statements does not depend upon  his vera-
city only, but must likewise rest, in a very great degree, upon
the character which he bears as a philosophical observer, and
the extent  of the  observations  on which his conclusions are
founded.   Hence  arises  the hesitation with which we receive
all  general statements, when made by  persons with  whose
opportunities of observation  and habits  of induction we are
not acquainted; and  the importance which we  attach to a
simple record of facts, in a concise and accessible form, apart
both from hypothesis and system.   The  author of such a re-
cord contributes that which has a fixed and certain value, de-
pendent  only upon his  correctness in  distinctly  describing
what he has seen ; and thus is furnished a series of facts which
every practitioner  may study for himself, and  from which he
may acquire a knowledge of phenomena, and of their relations
to each other, nearly in the same manner as he does from his
own observation.

  In the revolutions  of medical science, there has been, for
some years, a progressive and remarkable change of opinion, 
VI
PREFACE.
in regard to the mode of conducting  medical investigations.
There appears to have been a tacit but very general admission
of the fallacy of medical hypotheses, and the precarious nature
of general principles in medicine;  and there seems to be an
increasing conviction of the indispensable necessity, of found-
ing all our conclusions in medical science, upon an extensive
and  accurate acquaintance with  the  pathology  of disease.
The facts which are required  for this  purpose can be derived
only from the contributions of practical men ; and it is of the
utmost consequence that such persons should extensively re-
cord  their observations, as these must form the only basis on
which can be founded any legitimate principles in medical
science.

   General principles in physical science are nothing more
than  general facts,  or facts which are common to all the in-
dividuals  of  a particular  class ; and it is  only when they are
deduced  from a correct  examination of all these individuals,
that they can produce either truth or  utility.  When they have
been  framed  from a limited observation, they are, in  general
science, useless, and in medicine, dangerous; and  in  regard
to medical science we  may perhaps venture to assert, that the
purposes  of  practical  utility are  promoted  in  almost  an
equal degree, when a principle, which has been  proposed is
confirmed by the progress of observation, and when one, which
has been  received upon  inadequate  grounds, is shown to be
fallacious.

  Influenced by these considerations,  the  author of the fol-
lowing treatise has, from  time to time, submitted to the pro-
fession a series of researches, on various important subjects
of a pathological and practical  nature;  and he now intrudes
upon their attention with farther observations, in a more con- 
PREFACE.                      Vll
nected and more extended form.  In doing so he has no sys-
tem to support, and  no new doctrines to propose.   He  may
indulge in conjectures, but these he will keep entirely distinct
from the facts upon which they are founded.   He assumes no
higher character than that of a faithful relater of facts, which
a practice of considerable extent has brought under his view ;
and  he aspires to no higher  merit, than  to  contribute some-
thing towards enlarging our acquaintance with the phenomena
of disease.

   This volume is divided into four  parts.   The three first of
these  refer to diseases  of  the  Brain, arranged under  three
classes, the Inflammatory, the Apoplectic, and the Or-
ganic.   This arrangement will probably answer  every  prac-
tical purpose ; for, though the affections of the inflammatory
class  generally terminate by an apoplectic  state, or a state of
coma, and  the  organic  affections are  often distinguished by
 apoplectic paroxysms, yet, in a pathological point of view,  the
 classes appear to be sufficiently distinct, for the purpose  of  an
 arbitrary division of the  subject.  The fourth part refers  to the
 diseases of the Spinal  Cord, and its membranes;  and in  an
 appendix to this part, a slight outline is given  of the present
 state of our knowledge in regard to the pathology of Nerves. 
 
CONTENTS.
PART     I.
OF THE INFLAMMATORY  AFFECTIONS  OF THE
  BRAIN,.......1
                        SECTION I.

GENERAL  VIEW OF  THE  SYMPTOMS INDICAT-
  ING INFLAMMATORY  DISEASE  WITHIN  THE
  HEAD,.......3
                        SECTION II.

OF THE  PRINCIPAL SEATS  AND TERMINATIONS
  OF THE  DISEASE,      .      .  -          .      .14

Seats,      .......       14
      1. Dura Mater.
      2. Pia Mater and Arachnoid.
      3. Substance of the Hemispheres.
      4. Dense Central Parts—Fornix, Septum, &c.

Terminations,   ....«•.    14
      1. Fatal in the Inflammatory Stage.
      2. Serous Effusion.
      3. Deposition of False Membrane.
      4. Suppuration.
      5. Ramollissement, or Softening of the CerebTaJ Substance.
      6. Thickening of the Membranes, &c.
                          B 
X
contents
                         section  in.
                                                         Page
INFLAMMATION OF THE DURA MATER,      .        21

Idiopathic,       .      •      •             •       •      *  ,
Connected with Disease of the Ear and Caries of the Temporal
            Bone,......24
          with Disease of the Nose,   .      .       .      .31
          with Caries of the Bones of the Cranium,    .        32
          with Obliteration of the Lateral Sinus,    .      .     34
Chronic, with remarkable Thickening,     ...        35
                         SECTION  IV.

INFLAMMATION  OF   THE"  ARACHNOID AND  PIA
  MATER, OR MENENGITIS,    ....     39

§ 1. Simple Meningitis in the most common Form,      .       40
§ 2. Meningitis of very great Extent, with Obscure Symptoms,   43
§ 3. Meningitis of very small Extent, with Severe Symptoms,    44
§ 4. Meningitis of the Base,          .       .      .      .45
§ 5. Meningitis with Suppuration on  the Surface,       .       46
§ 6. Meningitis with Suppuration in the Ventricles,        .    47
§ 7. Meningitis of the Cerebellum,        ...       48
§ 8. Of a very  dangerous  Modification of  the Disease which
       shows only  increased Vascularity,     .      .      .49
                         SECTION V.

INFLAMMATION  OF   THE  SUBSTANCE  OF  THE
  HEMISPHERES,.....58

§  1. Fatal in the Inflammatory Stage,       .      .      .59
§  2. The Affection in a Chronic Form,   ...       63
§  3. The Inflamed Mass passing into Ramollissement,     .     66
§  4. Extensive Ramollissement of the Corpus Striatum,         69
§  5. The Affection in a Chronic Form, with Ramollissement of
       small Extent,  and remarkable Symptoms,     .      .     70
§  6. The Affection in a Chronic Form, with extensive Ramol-
       lissement and Remarkable Disease of the  Basilar Ar-
       tery,     .......     73
§  7. Ramollissement combined with Suppuration,       .       74
§  8. Undefined Suppuration,   .      .     .      .      .75
§  9. Extensive Undefined Suppuration with Extravasated Blood   77
§ 10.  The Encysted Abscess,         .     .      .      .  '  78
§ 11. Abscess of the  Corpus Striatum of very small Extent     83
§ 12. Abscess of the Medulla Oblongata,     .      .      '.84 
CONTENTS.
XI
                                                         Page
§ 13. Abscess of the Cerebellum,  ....       85
§14. Ulceration of the Brain,         .      •       •      .86
        General Review of the Subject,  ...       87
                        SECTION VI.

INFLAMMATION OF THE CENTRAL PARTS—COR-
  PUS  CALLOSUM,  FORNIX,  SEPTUM LUCIDUM,
  AND THE   MEMBRANE  LINING THE  VENTRI-
  CLES,        .......181

§ 1. Inflammation of the Membrane lining the Ventricles,      103
§ 2. The Inflammatory Origin of the  Ramollissement  of  the
       Septum Lucidum,      .....   104
§ 3. Ramollissement of the Central Parts, Fatal without Effu-
       sion,     .     .      •      •     •  .    •  .   •   1°5
§ 4. Ramollissement of the Central Parts, combined with  Se-
       rous Effusion, constituting  the most common form of
       Acute Hydrocephalus,      ....      107
       Cases illustrating some important Varieties in the Symp-
         toms,      ....••      iio
       The Affection occurring in Phthisical Cases,        .   113
§ 5. Cases of Simple Effusion,    .      .      •      •      1}6
        General Review of the Subject,    .      .      .lib
                        SECTION VII.

CAUSES OF  THE  INFLAMMATORY  AFFECTIONS
  OF THE BRAIN,.....m

1.  Febrile Diseases,     .       •      •       •      •      '   102
2.  Injuries,        •  ,           •      •      •      •        _„
3.  Suppressed Evacuations,     .      .      •  .    •      •   \**
4  Appearing in Connexion with other Chronic Diseases,       l^d
5.'  Passions—Stimulating Liquors—Heat of the Sun,  &c.    ,   124


                         SECTION VIII.

TREATMENT  OF  THE  INFLAMMATORY  AFFEC-
   TIONS,         ......125

Examples of Successful Cases under various Forms,        .    127 
Xll
CONTENTS.
APPENDIX  TO  PART  I
                       SECTION I.
                                                     Page
OF TUBERCULAR DISEASE  OF THE BRAIN,    .   134
                       SECTION II.

OF CERTAIN  AFFECTIONS OF  THE  BONES  OF
  THE CRANIUM,.....148
                       SECTION III.

OF CERTAIN  AFFECTIONS   OF  THE PERICRA-
  NIUM,       .......158
                     PART  II.



         OF THE APOPLECTIC AFFECTIONS.

                                                     Page
General View of the Subject,      ....      165
General View of the Symptoms, referred to Three Classes,  .    168


                        section i.

OF THE CASES OF THE FIRST CLASS, OR THOSE
  PRIMARILY APOPLECTIC,  .      .            .170

§ 1. Apoplexy without any Morbid Appearance, or Simple Apo-
      plexy,   .......171
§ 2. Apoplexy with Serous Effusion,      .      .      #      yje.
      Extensive Effusion  without any  Apoplectic Symp-
        toms,   .      .     .      .      .     .          i77 
CONTENTS.
xin
                                                   Page
Of the term, Serous Apoplexy,     .      .      .      178
Conclusions from a Review of this  part of the Sub-
  ject,    .......   180
                          SECTION II.

OF THE CASES OF THE SECOND CLASS, OR THOSE
  WHICH  BEGIN  WITH  A  VIOLENT  ATTACK OF
  HEADACH,  AND  PASS INTO  APOPLEXY GRA-
  DUALLY, .......181

§ 1. The Coma rapidly supervening on the First Attack,     .   183
§ 2. An interval of perfect recollection for several hours, betwixt
       the Attack and the Occurrence of Coma   .      .      185
§ 3. An interval of three days between the Attack and the Occur-
        rence of Coma,  ......   187
§ 4. The fatal Coma occurring  a fortnight after the First Attack, 188
§ 5. Two distinct Extravasations,   ....      189
§ 6. The Extravasation confined to the Third and  Fourth Ven-
       tricles, with remarkable Disease of the Arteries of the
       Brain,    .......   190
§ 7. Extravasation on the Surface  of the Brain,   .       .      191
§ 8. Extravasation in  the Cerebellum,  ....   194
§ 9. Extravasation  in the Substance  of  the  Tuber Annu-
        lare,   .......195
§ 10.  Extravasation in all  the  Ventricles, and  along  the whole
        course of the Spinal Cord,      ....   197
§11.  Extravasation in a Cyst, formed by separation of the laminae
        of the dura mater, from rupture of the middle Meningeal
         Artery,     .      .       .      .      .      .      198
        Review of the Subject, and of the various Sources of the
         Haemorrhage in Cases of this Class,        .   .  .   199
        Of Disease of the Arteries of the Brain,   .      .      201
        Similar Disease of the  Veins,   ....   202
                          SECTION II.

OF THE CASES OF  THE THIRD CLASS, OR  THE
  PARALYTIC. CASES,.....204

§ 1. Paralysis  wkh Serous  Effusion, or with slight Morbid Ap-
        pearances,       ....             .   206
§ 2. Paralysis with Extravasation of Blood of small extent  -  209
       Progress of these  Cases—Formation of a Cyst—and
         Absorption of the Coagulum,    .      .       .      209
           A.  The Cyst empty—-the Patient  dying of another
             Disease,    ......  213
           B.  The Cyst empty—the Patient dying of a fresh
             Attack,.......217 
XIV
CONTENTS.
                                                  Page
C. Two Cysts empty—the Coagulum  partly absorbed
       from a Third—the Patient dying of a fresh Attack,   .  218
     J.  The Cyst on the Surface,      .      •      '      ooq
3. Paralysis with Ramollissement,   .      .      •      'tit
. i-»___i„_:___:.u i^Aomirotinti atifl ite Cnnsfirmences.   .      <z&l
§ 4. Paralysis with Inflammation and its Consequences,
       General Observations on Paralysis,    .      .          f*°
       General Pathology of Paralysis,    .      •      •      *31
                         SECTION IV.

OUTLINE OF THE TREATMENT OF APOPLEXY   238
APPENDIX  TO PART  II.
CONJECTURES IN REGARD TO THE CIRCULATION
  IN THE BRAIN,.....248
PART  III.
OF THE ORGANIC DISEASES OF THE BRAIN,   .   260

1.  Tumors formed by Thickening of the Membranes, &c. .      260
2.  Deposition of Albuminous Matter,   ....   260
3.  Dense White Tumor, apparently not Organized,       .      261
4. Flesh-coloured Organized Tumor,   .       .      .       .261
5.  Tubecular Disease,      *      .      .      .      .      261
6.  Induration of the Cerebral Substance,      .     .      .   262
7. Ossifications,     ......      262
8. Hydatids,    .....      .         262
OUTLINE OF THE SYMPTOMS REFERRED TO  SE-
                    VEN CLASSES.
1. Headach, without any other remarkable Symptom, .       .   264
2. Headach, with Affections of the Senses, .      .       .      265 
CONTENTS.
XV
                                                      Page
3. Headach, Affections of the Senses, Convulsion,   .     .   265
4. Convulsion, without Affections of the Senses,  .      .      266
5. Cases with Paralysis, ....••   267
6. The Prominent Symptoms in the Stomach?    .      .      267
7. Cases with Slight and Transient Apoplectic Affections,  .   268
                     PART  IV.



OF THE DISEASES OF THE SPINAL CORD AND ITS
  MEMBRANES,......272


                        SECTION I.

MENINGITIS OF THE CORD,   .      .      .     .274


                        SECTION II.

INFLAMMATION  OF THE  SUBSTANCE  OF THE
  CORD,.......280

§ 1. Fatal in the Inflammatory stage, ....   281
§ 2. Ramollissement of the Cord,                           282
§ 3. Undefined Suppuration,     .      .     .               294
§ 4. *Abscess,  .......      296


                        SECTION III.

SEROUS EFFUSION IN THE  SPINAL CANAL,    .   297


                        SECTION IV.

SPINAL APOPLEXY,.....299


                         SECTION V.

 THICKENING  AND  FUNGOID DISEASE  OF  THE
   MEMBRANES, AND FUNGUS OF  THE  CORD IT-
   SELF,  ........302 
XIV
CONTENTS.
                     SECTION VI.

INDURATION OF THE SPINAL  CORD,   .           305
                     SECTION VII.

NEW FORMATIONS COMPRESSING THE  SPINAL
  CORD,.......305
                     SECTION VIII.

DESTRUCTION OF A PORTION  OF  THE SPINAL
  CORD,.......309
                     SECTION IX.

CONCUSSION OF THE SPINAL CORD,     .     .310
                     SECTION X.

OF CERTAIN AFFECTIONS OF THE BONES OF THE
  SPINE,   .......     316
                     SECTION XI.

CONCLUDING OBSERVATIONS  ON THE PATHOLO-
  GY OF THE SPINAL CORD, WITH REFERENCE TO
  VARIOUS ANOMALOUS AFFECTIONS,   .      .   325
         APPENDIX  TO  PART IV.

OUTLINE OF THE DISEASES OF NERVES,
SELECTION OF CASES  ILLUSTRATIVE  OF  THE
  ORGANIC DISEASES OF THE BRAIN, BEING A
  SUPPLEMENT TO PART HI.  . 
          DISEASES

               OF


THE  BRAIN,  &c-
                       PART  I.


  OF THE INFLAMMATORY AFFECTIONS OF THE
                         BRAIN.

  Peculiar difficulties attend the investigation of inflammato-
ry affections of the brain.  In the inflammatory diseases of other
organs, we are generally able to trace the' proper symptoms of
the inflammation through the whole course of the disease, and
to make  allowance for any incidental combinations by which
they may be modified; but  from the rapid  effects which all
acute diseases of the brain produce upon the sensorial functions,
the patient generally becomes,  at an early period,  unable  to
express his feelings, and the proper symptoms of the disease
are lost amid that suspension of all the faculties to  which we
give the name of oppression  of the brain.
  Whenever  this remarkable condition occurs, it naturally
becomes  the  prominent object  of  attention; and,  as it has
been by long-established usage strongly associated with  the
idea of pressure upon the brain, the investigation has generally
been directed to the discovery of a compressing cause. Effused
fluid having been found, upon  examination  after death, in a
great proportion of the cases  referred to, has,  on this principle,
been considered as explaining the symptoms,  and here, proba-
bly, the investigation ha s closed.
  This course of inquiry seems  to have been the  occasion  of
much of  that obscurity which so long involved the  pathology
of affections of the brain, particularly the  pathology of  acute
                            1 
2             INFLAMMATORY AFFECTIONS.
hydrocephalus.  More extensive acquaintance with the phe-
nomena of this class of diseases has shown us that the course
was fallacious, and has enabled us to ascertain principles of
the utmost practical importance.    We have learned, that the
condition which  we denominate coma, with its usual conco-
mitant symptoms, is not characteristic  of any one condition of
the brain, but that it may exist in connexion with  diseases
which are very different, or even opposite in their nature ; that
it does not prove the existence of any compressing cause, and
particularly that  it has no necessary connexion with effusion
in the brain ; farther, that effusion to a great extent  may ex-
ist  in the  brain,  without producing any of the symptoms
which have usually been ascribed to it, and, in particular, that
these  may all exist in connexion with  a state of disease which
is simply inflammatory.  Following the light thus obtained,
we find in the phenomena accompanying inflammation  of the
brain  and its membranes, a subject of much interest and great
extent, and one which leads to results of the highest practical
value. When applied to the pathology of the disease common-
ly called acute hydrocephalus, the importance of this investi-
gation is  particularly apparent.   For I  think we may now
consider it as ascertained, that this formidable malady is not a
mere  dropsical affection of the brain, but an inflammatory dis-
ease terminating by effusion; that many of the leading symp-
toms  are not connected with the effusion, but with the inflam-
matory condition which goes before it;  and that without any
effusion it may be fatal,with all the symptoms which have usual-
ly been considered as characteristic of hydrocephalus.
   When we enter more particularly upon  this inquiry, we find
inflammatory disease  in the brain varying considerably in its
characters in different  cases. These varieties appear  to be re-
ferable to three circumstances ;—the seat of the inflammation
—its  degree of activity—and the mode of its termination  It
may be seated in the Dura Mater, the Pia Mater, the Arach-
noid, the substance of the Hemispheres, or the deep-seated
central parts  of  the brain.   In  its activity, it varies  from the
highest degree  of  active inflammation,  to the  chronic or
scrofulous inflammation with the  lowest degree  of  activity
and with numerous modifications by which the different forms
pass  into one another by almost  insensible  gradations  It
may terminate by serous effusion, by  the  deposition of false
membrane, by suppuration,  or  by the ramollissement  of the
cerebral substance.   The phenomena  resulting  from  these 
SYMPTOMS.
3
several varieties, present to us a field of investigation of great
extent and considerable difficulty.   But before entering upon
the inquiry, it will be advisable to take a general view of the
symptoms which indicate inflammation of the parts within the
head.
                      SECTION I.

GENERAL VIEW OF THE SYMPTOMS WHICH INDICATE INFLAM-
           MATORY DISEASE WITHIN THE HEAD.

  Our knowledge of this subject is not sufficiently matured, to
enable us to say with confidence what symptoms indicate in-
flammation of the  substance of  the brain, as  distinguished
from inflammation of  its  membranes ; but  the  distinction is
not of much  practical importance, and  our present purpose
will be  answered by a general  view of  the  symptoms which
indicate inflammation of any of the parts within the cranium.
  They appear under a variety of forms, depending probably,
either upon the activity of the disease, or the particular part
which is the seat of the inflammation.   The leading modifi-
cations, as they occur to us in practice, may be referred to the
following heads.
  I.  As the  first form of the disease, perhaps we ought to
place the Phrenitis of systematic  writers.  It is characterized
by  fever, watchfulness, acute  headach, impatience  of light,
suffusion of the eyes, and maniacal delirium.  This affection,
however, is seldom met with as an idiopathic disease, except
in a few cases in which it is  brought  on by the abuse of strong
liquors, and in warm climates by exposure to the intense heat
of the sun.   As a symptomatic affection, it is met with occa-
sionally in fever, and in mania; and a condition nearly allied
to  it sometimes  occurs after injuries of the head.   Circum-
stances will  be afterwards mentioned, which render it proba-
ble that in this form of the disease, the inflammation is primarily
seated  in  the  membranes  of the brain.   When  fatal, it is
generally by a rapid sinking of the vital powers supervening
upon the  high excitement, without producing much disorgan-
ization of the parts which appear to have been  the seat of the 
4
INFLAMMATORY  AFFECTIONS.
disease;  for the cases which are referable to this class, when
they terminate fatally, are generally rapid  in their progress,
and the appearances on  dissection are often unsatisfactory.
There  is  an affection  of  frequent occurrence, which perhaps
may be referred to this head.   It is characterized by a pecu-
liar aberration of mind without any complaint of pain.  There
is  a remarkable  restlessness, quickness and impatience  of
manner, obstinate watchfulness,  and incessant, rapid talking,
the patient rambling from one  subject to another, with little
connexion, but  often without any actual  hallucination.   He
knows those  about him, and  generally answers distinctly
questions  that are put to him.  There is a rapid  pulse, but
without the other symptoms of fever;  and the disease is apt
to  be mistaken by a superficial observer for  mania, and con-
sequently to be considered as not being attended with danger.
But it  is an affection of great danger, and is often very rapid-
ly  fatal.   The nature of  it is obscure,  and the appearance on
dissection  is  rather unsatisfactory;  it consists  chiefly of  a
highly vascular state of the Pia Mater, without any actual result
of inflammation.
   II. In  a second form  of the disease, which  is worthy of
much attention, the first symptom that excites alarm is a sud-
den attack of convulsion.   This in  some cases occurs with-
out any previous illness ; in others it is preceded by slight com-
plaints which had attracted little attention ;—in one case which
will be described, it was  preceded by vomiting, in another by
slight headach for several days.  The  convulsion is generally
long and severe; in some cases  it is followed immediately by
coma,  which in a few days is fatal; in others, the convulsion
recurs  frequently at short intervals, the patient in the intervals
being sensible and complaining  of headach, and  after twelve
or twenty-four hours, passes into coma.  Sometimes after the
coma  has  continued for  a  certain time, perhaps for twelve
hours, there  is a complete recovery from it;  and  for several
days the  patient appears to be in the  most favourable  state
when, without an^ warning, the convulsion  returns, and  ter-
minates in fatal  coma.   In  a very interesting modification of
this form  of the disease, the convulsion is confined to one side
of the body,  or to  one limb,  and  is usually followed by paraly-
sis of the part affected;  and in  some cases, the first symptom
is a sudden attack of  paralysis without the preceding convul-
sion.  These cases are remarkable from their resemblance to
the  ordinary attack of hemiplegia.   It will appear  in  the 
SYMPTOMS.
5
sequal, that they are often connected with inflammation of a
small defined part of the  cerebral  substance;  that the attack
may be so sudden as precisely to resemble the paralytic attack
from other causes ;  and that the disease in the brain may not
have advanced beyond the state of simple inflammation, while
the symptoms have gone  through  the usual course, and have
terminated in fatal coma.  In  general, however, the disease
in such  cases will be found to have advanced  to suppuration,
or to the ramollissement or peculiar softening  of the cerebral
substance, to be  afterwards more particularly referred to;
while, on the other hand, in some very interesting cases  of
this class, the inflammation will be  found to have been entirely
seated in the membranes.
   III. The third form of  the disease most  commonly affects
children, but may also appear in adults.   It is usually preced-
ed for a day or  two by languor and  peevishness:  these  are
followed by an accession of fever, which is sometimes ushered
in by severe shivering.  The patient is  oppressed  and unwil-
ling to be disturbed, and complains of acute pain in some part
of the head, with flushing of the face  and impatience of light.
In many cases there is frequent  vomiting, which continues
for the first day or two; in others, the vomiting is absent.
The pain is felt in various parts of the head ; frequently  it ex-
tends along the neck;  and sometimes  pain is complained of
in the arms and in other parts of the body.   The pupil is usu-
 ally contracted;  the eye  is morbidly  sensible, and sometimes
 suffused; the tongue is generally white, but moist; sometimes
 quite clean.  The sleep  is disturbed by starting and frightful
 dreams, and frequently during sleep  there is  violent grinding
 of the teeth.  The bowels are generally obstinate, but frequent-
 ly they are natural; and  I  have  seen  the  disease attended
 through its whole  course by a spontaneous diarrhoea.  After
 some days, slight delirium begins  to appear, at first transient,
 perhaps only observed during the  night, or on first awakening
 out of  sleep; or in some cases the patient  lies in a dozing
 state, and talking incoherently, but out  of * which he can be
 roused so as to talk sensibly.   In other cases, instead of de-
 lirium, there occurs a peculiar  forgetfulness, the patient using
 one word instead of another, misnaming persons and things,
 mistaking  the  day, or the time of day, or showing in some
 similar  manner a confusion  of thought, which has no resem-
 blance to the delirium of fever.   Sometimes  he is sensible of
 it, and appears anxious to correct the mistakes which he has 
6
INFLAMMATORY AFFECTIONS.
made.   These symptoms are followed by a tendency to sleep,
and this soon passes into coma.  While these symptoms are
going on, the pulse, which was at first frequent, usually falls
to the natural  standard  or below it;  the pain becomes less
violent;  the eye loses its acute sensibility, becoming dull and
vacant, often with squinting  and double vision; and these are
often  succeeded by dilated  pupil and blindness, even before
the patient falls into coma.  The pulse, having  continued
slow for a day or two, sometimes only a  few hours, begins to
rise again, and rises to extreme frequency ; it has been.count-
ed as  high  as two hundred in a minute.  It is  through the
whole course of the disease extremely unequal in  frequency,
varying perhaps every minute, or every time that it is counted.
This remarkable inequality  is not observed in other diseases,
except from some temporary cause, and is, in all affections of
the head, a symptom deserving much attention.  The patient
is now in a state of perfect coma, sometimes with paralysis of
one or more of the limbs, sometimes with convulsive affec-
tions ;  and, after he has continued in this state for a few days,
the disease  is  fatal.  The  duration of  the complaint is ex-
tremely various ; it is in some cases drawTn out to three weeks,
and in others, especially in young children, it is fatal in five
or six days.   At some period of the disease, there  is  general-
ly a remarkable remission of all the symptoms, giving sanguine
but deceitful hopes of  recovery.  This  usually occurs when
the pulse is falling in frequency, or when it is beginning to
rise after the slowness, and it is generally the prelude to coma.
In some eases the pulse  does not become slow, but continues
through the whole course of the disease of nearly uniform fre-
quency.—In young children who cannot describe their feelings,
this  form of the disease is characterized by fever, flushing,
restlessness, and screaming, often with vomiting ; these symp-
toms  are succeeded in a few days by stupor and squinting,
the pulse coming  down  as  the stupor appears.  This falling
of the pulse, while the child continues in a state of great op-
pression, approaching to coma, is  often the first symptom
which points out the alarming nature of the disease.
   IV. The fourth form of the disease, I have observed most
commonly in  young persons towards the age of puberty and
upwards.  It begins like a slight feverish disorder, and for  a
 considerable time excites no alarm.   There is slight headach
 with general uneasiness of the limbs, impaired  appetite and
 disturbed sleep;  the tongue is. foul, and the pulse slightly fre- 
SYMPTOMS.
.7
quent, probably from 96 to 100.   After a few days the com-
plaint appears to be going off; but, at  our  next visit, we are
disappointed  to find the patient complaining as much as at
first.  More  active treatment is then  adopted, and  there is
again an appearance of amendment; the tongue perhaps be-
comes clean, there is  some  appetite, and  better sleep :  but
there is still some  complaint  of headach, which varies much
in degree from one day to another, never  severe, but never
quite gone ;  the  pulse continuing a little frequent.  Amid
these remissions and aggravations, eight or ten days  may pass
before the disease has  assumed any decided character.  It is
not perhaps before the  sixth or seventh  day, that even an at-
tentive observer begins to remark, that the degree of headach,
though  not severe, is greater and  more permanent than  cor-
responds with the general symptoms of fever; that the tongue
is becoming clean, the pulse  coming down, and the  appetite
improving, while  the headach continues, with an unwilling-
ness to be disturbed, and a degree of oppression which is not
accounted for by the degree of fever.  In this manner the dis-
ease may go  on for several  days  more, until, perhaps about
the 12th or 14th day, the pulse  suddenly falls to the natural
standard, or below it, while the headach is increased, with an
evident tendency  to stupor.   This instantly marks a head af-
fection of the most dangerous character, and the patient  now
lies  for several days in a state of  considerable  stupor, some-
times with  convulsion, often with squinting and double vision.
The pulse then begins to. rise again, and about this time there
is frequently  a deceitful interval of apparent  amendment;
sometimes  the squinting goes off, and the eye appears quite
natural, the stupor is  lessened,  and the patient appears  easy
and intelligent, and soon relapses into perfect coma,  and dies
in three or four days.  The duration of the disease  is uncer-
tain ; it may be drawn out to five or six weeks, or it may be
fatal in two or three.—When this form of the disease attacks
infants, they are  observed to be languid and oppressed,  with
bad appetite, and disturbed sleep ; there is often a disordered
state of the bowels, and to this cause the affection is  probably
ascribed.  There  is no urgent symptom, and no alarm is ex-
cited until, after eight or ten days, the  pulse is found at 70 or
60,  the pupil dilated, the eye fixed and vacant, and  the child
in a state of oppression  tending to stupor;  these symptoms
are  soon followed  by coma, generally with squinting, and in
a few days by death.—This  form of the disease  might have 
8              INFLAMMATORY AFFECTIONS.
been considered as a modification of the former, as the symp-
toms  differ only in degree; but I have thought it worthy of
a separate description, on account of the insidious characters
which it exhibits in the early stages, and because it is a form
of very frequent occurrence.  Cases  indeed occur in which
there  is still less appearance of an affection of the head, than
I have supposed in this description, and in which there is  not
even  the slightest complaint of headach through the whole
course of the disease.
  V.  The fifth form  of the disease I have usually observed in
adults ; and  it begins  with  violent headach without fever.
The patient is found  in bed, lying oppressed and unwilling to
be  disturbed, or tossing about from the violence  of the pain.
The pulse is  about the natural standard, or below it, frequent-
ly about 60;  the face in some cases flushed, in others, rather
pale; in some cases the  eye is natural, in others,  there is
impatience of light, with contracted pupil.  The  pain is usu-
ally very acute and  deep-seated, and is referred to  various
parts  of the head; frequently it seems to shoot from temple to
temple, and  sometimes it is referred to the ear.   There is a
look of much oppression, and in some cases vomiting. Delirium
frequently appears at an early period, varying in  degree from
day to day, until after five or six days it passes into fatal coma,
the pulse having continued from 70 to 80 through the whole
course of  the disease.  In other cases, the pulse  is at  first
about the natural standard, afterwards falls to 60 or 50,  and
at last rises to 120 or 130.   The vision is in some cases  not
affected; in  others squinting and  double vision  occur,  and
sometimes these symptoms, after continuing for a day or two,
disappear not to return;  the disease, notwithstanding, going
on  to a fatal termination.   There is in every case  more or  less
delirium, but  often slight  and transient;  and  frequently  the
patient lies in a dozing state, and talking incoherently, but out
of which he can be roused, so as to talk sensibly.  This con-
dition, when it is not accompanied by fever, is always charac-
teristic of  a  dangerous affection of the brain.  There is  also
frequently observed  that pecular forgetfulness or  confusion of
thought formerly referred to, which is different from any thing
that occurs in fever, and always indicates a dangerous  cerebral
disease.  Sometimes there is difficulty  of articulation;  and
frequently a hesitation in speaking, from the patient not being
able to recollect the  word which  he intended to make use of.
 There  is  generally towards the end more or less coma, which 
SYMPTOMS.
9
in some cases continues  three or four days, in others  not
above twelve hours ; and sometimes the disease is fatal with-
out perfect coma, the patient being able to answer questions
distinctly a very short time before death.
  To these forms of the  disease, other modifications might
have been  added, but it is impossible to include, in any de-
scription, all the varieties in the symptoms.   One variety has
been added by M. Gendrin, which is worthy of attention.  It
comes  on in a very  insidious  manner,  at first often without
either headach or fever.   There is chiefly observed a certain
obscuration of the mental functions, accompanied with lassi-
tude and an appearance of mental depression.  The  patient
seems  scarcely to comprehend what is said to him,—asks the
same question several  times  in succession,—and  answers
questions put to him with  slowness and  hesitation.  He  com-
plains  of little unless a general feeling  of being indisposed;
and thus the symptoms creep on gradually with disturbed sleep,
and slight rigors,  till they pass into slight delirium, and at last
into coma; the pulse, which was  at first not affected, becom-
ing rapid as the disease advances.
  In all the forms of this  dangerous affection, there is  great
variety in the  symptoms, and much  observation is required to
put us fully upon our guard against  the insidious characters
which many of the cases  assume, and  the  deceitful  appear-
ances of amendment which often  take  place in  all the forms
of the disease.  Even in those cases which have assumed the
most formidable  aspect, every alarming symptom may sub-
side.   The pulse  perhaps continues frequent, but  it also  is
coming down ; at our successive  visits we find it falling re-
gularly, and we are disposed to hope  that a few  days will
bring the case to a favourable termination.   During this de-
ceitful interval, which may continue  for several  days, I have
known a parent intimate to the medical attendant that his far-
ther  visits were unnecessary,  and I have known a  physician
take his leave, considering his patient  as convalescent.   As
the pulse falls, the patient is disposed to sleep; this perhaps is
considered  as  favourable ;  it falls to the natural standard—he
then sleeps almost constantly; and in another day this  sleep
terminates in coma.   The pulse then begins to rise again ;  it
rises to extreme frequency, and in a few  days more  the pa-
tient dies.   All this  may go on with very little  complaint of
headach, and without any symptom that will lead a superficial
observer to suspect  danger, until he finds his patient gliding
                            2 
10
INFLAMMATORY AFFECTIONS.
into coma at the very time when he expects recovery ; for the
period when the pulse falls to the natural standard is the time
when the coma becomes evident, and the situation of the pa-
tient probably hopeless.   Whenever, therefore, at any period
of a febrile disease, there have been remarkable symptoms in
the head, such as violent headach, with vomiting and impa-
tience of light, stupor, convulsive affections, or affections of
the sight,—though these symptoms may have  entirely  sub-
sided, and the complaint may again have assumed the cha-
racters of  simple fever, we must not consider the danger as
over, but must be upon our guard against a period of anxiety
which is still before us.   An attentive observer may generally
remark, in such cases, something which leads him to suspect,
that the appearance of  amendment is deceitful.   Sometimes
there is a dilated state of the pupil, giving to the eye a pecu-
liar expression, and sometimes there is a remarkable tendency
to sleep.  Frequently something unusual may be observed in
the patient's  manner, such  as a fretfulness or querulousness
which is not natural to him,—a quick  and hurried manner of
speaking,  or, on  the  contrary, a  remarkable  slowness of
speech ; difficult articulation, or a peculiar confusion of thought
and forgetfulness on particular subjects.  But  it cannot be
too strongly impressed upon  the younger  part of the profes-
sion, that  cases occur in which all these symptoms are want-
ing, and in which the patient appears for several days to be in
the most hopeful state of recovery, while in fact his disease
is advancing rapidly to a fatal termination.

   In this  description  I have been entirely practical;  and I
have not entered upon the inquiry, whether all the forms of
disease which I have mentioned are to be considered as pri-
mary and  idiopathic affections of the brain, or whether  some
of them ought to be looked  upon as secondary or symptoma-
tic.   It is, however, an  important fact, that this disorder does
very often occur as a symptomatic affection in the course of
other diseases;  the most common of which are,—continued
fever,—scarlatina,—hooping cough,—measles, pneumonia,__
phthisis, and diseases of the  kidnies.   It may be useful, there-
fore, to keep in view those symptoms, which, in the course of
any disease,  indicate  a tendency to this  dangerous affection
of the brain.  They are chiefly the following:
In the Head.—Violent headach with throbbing and giddi 
SYMPTOMS.
11
         especially if*the pain  be referred to a particular
         spot, and always to the same part,—tinnitus—sense
         of weight and fulness—^stupor—a great propensity
         to sleep.  In many  obscure and insidious cases, a
         constant feeling of giddiness is the only remarkable
         symptom*

In the Eye.—Impatience of light—unusual contraction or di-
         latation of the pupil—double  vision—squinting—
         blindness—distortion of the eyes outwards—para-
         lysis of the muscles of the eyelids, producing, ac-
         cording to  the muscle  that is affected,  either the
         shut eye or  the gaping eye—transient  attacks of
        • blindness—or double vision—objects seen  that do
         not exist—a long-sighted person suddenly recover-
         ing ordinary vision.

In the  Ear.—Transient attacks of deafness—great noise in
         the ears—unusual acuteness of hearing.

In the Speech.—Indistinct or difficult  articulation—unusual
         quickness of  speech, or unusual slowness.

In the Pulse.—Slowness and remarkable variations in  fre^
         quency.

Inthe Mind.—High delirium—transient fits of incoherence—
         peculiar confusion of thought, and forgetfulness on
         particular topics.
In the Muscles.^-Paralytic and convulsive affections—some-
         times confined to one limb,  or even a part of a limb ;
         and a state of rigid contraction of particular limbs.

In the Organs of Touch.—Diminution or  loss of sensation in
         a  limb, or  often a very small part of a limb,—and
         various morbid conditions of sensation.

In the Urine.—There.frequently occurs a remarkable diminu-
         tion of the secretion—-sometimes nearly  amounting
         to complete suppression; and  connected with  this
         diminution there is often a frequent desire  to  pass
         urine,  occasioned  probably by the  increased  acri-
         mony, as the quantity diminishes. 
12
INFLAMMATORY AFFECTIONS.
   In this important  diagnosis, however, minute  attention to
the correspondence of the symptoms is of more importance than
any particular symptom ; thus, the peculiar oppression which
accompanies a high degree of fever is familiar to every one,
and is not reckoned an unfavourable  symptom; the same de-
gree of oppression occurring without fever, or with very slight
fever, would indicate a head  affection of the most dangerous
character.   In the same manner, a degree of headach and of
delirium, which, accompanying a high degree of fever, would
be considered  as  symptomatic, accompanying slight  fever,
would indicate a dangerous affection of the brain.

   In the preceding outline, the symptoms have been described
from the cases of most frequent  occurrence.  We meet with
numerous varieties which it is impossible to include under any
general description.  One of the  most remarkable modifica-
tions is that which comes on  with a sudden attack of palsy,
so as to be considered as an apoplectic rather than an inflam-
matory affection :  it is generally connected with inflammation
of a portion of the cerebral substance, but may also occur in
connexion with inflammation of the  membranes.  This form
of the disease may also take place in a more chronic  manner,
in which it goes on for months.   In such cases, it is generally
distinguished by headach, often confined to one side of the
head—loss  of memory—affections of various organs, as the
eye,  the ear, or the tongue—convulsive  affections—palsy of
one limb, or one side of the body, and at last ends by coma
and  death.   In such case ramollissement  of a  part of the
brain is  generally met with, but sometimes  the part  is  found
of a dark red colour, and rather firmer than the  surrounding
parts.
   In the particular  symptoms, likewise,  numerous  varieties
occur, as, for example, in  the state of the pupil:   in some
cases it  continues sensible to the last, and in others  it is un-
usually contracted ; sometimes, after being dilated and insen-
sible, it again becomes sensible:  occasionally  one  pupil is
found to  contract, while the other is dilated and insensible.
Alternate contraction and dilatation  may  also be observed •
and a singular condition of the pupil is sometimes met  with'
in which it becomes dilated on the approach of a bright light!
I have observed this  several times, and am  quite satisfied of
the fact,  but am unable to point out  the particular  nature of
the cases in which it occurs.   It will be found exemplified in 
SYMPTOMS.
13
 one of the cases to be afterwards described.   Remarkable re-
 coveries of the senses also occur, often a short time before
 death.  Some time  ago I  saw a  boy  aged seven, who  had
 perfect blindness and loss of hearing, followed by coma; three
 days after the occurrence  of these symptoms, he recovered
 his sight and hearing for a  few hours, knew those about him,
 and talked sensibly; then  relapsed into coma, and died next
 day.  The usual appearances were  found on  dissection, the
 effusion being large in quantity.  I have also seen  squinting
 continue for a day or  two, and then  disappear, the disease
 running its course  to a fatal termination without any recur-
 rence of it.

   In the preceding observations I have said little in regard
 to the state of the bowels, because I am satisfied that there is
 no condition  of them which  is peculiar or essential  to  this
 class of diseases.  They are generally obstinate, but some-
 times easily  regulated, and sometimes spontaneously loose
 through the whole course of the disease.  The motions  also
 vary exceedingly in character, exhibiting  in different cases,
 and at different periods of the, same case, all the various forms
 of morbid appearance, which  are met with in  other febrile
 diseases.  One of the  most  common  is the evacuation  of
 much green matter like tea-leaves, or  chopped spinage;  and
 this, I believe, is the appearance which has been considered
 so peculiar to affections of  the brain, as to have  received the
 name of hydrocephalic stools.  This  doctrine, I am satisfied,
 is entirely unfounded in point of fact,  and therefore, when  it
 is proposed as a rule of diagnosis, I must consider it as highly
 dangerous.   Every practitioner who divests himself of sys-
 tem, and attends to what is passing before him, will find,  that
 the character of stools here referred to, is by no  means pecu-
 liar to affections of the brain;  and that hydrocephalus runs its
 course with every possible  variety in  the appearance of the
 evacuations, and that even  at the  most advanced  periods  of
 the disease, they may often be found perfectly natural.  While
 it is therefore proper that, in the investigation of this disease,
 every attention shall be paid to the  character of the evacua-
 tions, and every means used to correct them  when  they are
 morbid, I must consider it  as  erroneous in  principle, and  in
'practice dangerous, to suppose that any  particular  character
 of stools is characteristic of hydrocephalus. 
14
INFLAMMATORY AFFECTIONS.
SECTION II.
 OF  THE  PRINCIPAL  SEATS  AND  TERMINATIONS  OF  THE
                        DISEASE.

  The preceding outline will serve as a general view of the
symptoms, which indicate inflammatory action of some of the
parts within  the  head.   When we come to investigate this
class of diseases in a pathological point of view, they resolve
themselves into important varieties, arising probably from the
particular part which is the primary seat of the disease ; and
important modifications depending upon the manner in which
the inflammation terminates.
  The varieties of the seat of the inflammation may be re-
ferred to the following heads.
  I.  The Dura Mater.
  II. The Pia Mater and  the  Arachnoid.   These may be
takeo together, both because it is extremely difficult to dis-
tinguish inflammation of the Pia Mater from inflammation  of
the Arachnoid, and  because, in point of fact, they seem  in
general to be affected at the same time.
  III. The substance of the Hemispheres.
  IV.  The dense white matter forming  the  central parts  of
the brain,—the septum  lucidum, the fornix, and the corpus
callosum.
  To investigate the phenomena connected with these various
seats of disease, will be one  of the objects of the  following
dissertations ;  and at the same time it will be of consequence
to keep in view the  peculiarities arising from  the  modes  in
which the inflammation terminates.   These  are chiefly the
following.   The disease may be fatal.
  I.  In the Inflammatory Stage, and this may occur, whether
it be seated  in the substance of  the  brain, or in the mem-
branes, especially the Pia Mater.   In the most  distinctly
marked cases, however, of this termination, the inflammation
is found in the substance of the hemispheres.
  II. By  Serous  Effusion.   In  the  earlier investigations  of
this class of diseases, too much importance was  perhaps at- 
TERMINATIONS.
15
tached to the effusion, as if it alone constituted the disease
called acute hydrocephalus.   The symptoms were ascribed to
the compressing influence of the effused fluid, and the prac-
tice was directed chiefly or entirely to promoting its absorption.
It is now, I imagine, very generally admitted, that the effu-
sion in acute hydrocephalus is to be considered as one of the
terminations  of inflammatory action,  though there are cer-
tainly other causes, from which serous effusion in those parts
may arise.
   Increased effusion from a serous membrane, appears to take
place under two very different conditions of the part:—
   (1.) Inflammation of  the  membrane itself, or of the parts
immediately adjacent to it.   In this manner  we  see  effusion
take place in the cavities of the Pleura, and the Peritonaeum',
from inflammation of these  membranes.  The effusion in such
cases varies considerably in its character, being in some cases
limpid, in others opaque and milky, and in others mixed'with
yellow flocculent matter, or sometimes being nearly purulent.
It is difficult to  say  on what these varieties depend.  We
may perhaps be allowed to  ascribe them in  some degree to
the heat of the inflammation, and to  suppose that when  the
membrane itself is inflamed, the fluid  will be flocculent; and
that it will be limpid, when the inflammation is seated in the
parts which the membrane  covers, the serous  vessels of the
membrane being  thus affected only  in a secondary manner.
We observe the same varieties in the appearance of the ef-
fused fluid in the brain, which we find in the other serous
cavities ; and upon the  whole view  of the  pathology of th-j
disease, we may consider the principle  as  fully established,
that inflammatory action is  the source of the effusion  in  all
those acute affections of the brain, which have generally been
included under the term acute hydrocephalus.
   (2.) There is, however, another source  of serous  effusion
entirely distinct from this, viz., interruption of the circulation
in the veins in any part  of the body.  In this manner, we see
a tightly bandaged limb become oedematous below the seat of
the pressure, and we find anasarca of  the whole or part of a
limb produced by the pressure of tumours, and ascites arising
from  induration of the  liver.  Whenever such interruption
occurs in the circulation of a vein, it  appears that increased
effusion takes place from the exhalant branches of those ar-
teries with which  the vein  is more immediately  connected,
depending probably upon a state of congestion in these parts, 
16              INFLAMMATORY affectons.
which in its effects is nearly analogous to inflammation.  Such
a state of impeded  circulation evidently takes place in the
brain from a variety of causes ;  such as the pressure of tu-
mours, chronic disease of the sinuses, tumours on  the neck,
certain diseases of the lungs and of the heart, and probably
from that very remarkable condition of  the  brain to which I
have proposed to give the name of simple apoplexy.  From
serous effusion produced by  such  causes  as these, probably
arise those  affections which have been called  Chronic  Hy-
drocephalus and Serous  Apoplexy.
  In regard to its seat, the effusion  of course varies In dif-
ferent cases.  It is found in the ventricles,—under the arach-
noid,—betwixt the arachnoid and  dura  mater ;—and  there
is every reason to believe that it also takes place betwixt the
dura mater and the bone, though the fluid effused in this si-
tuation escapes when the head is opened.    It is occasionally
met with in a cavity formed by  the separation of the laminse
of the septum lucidum.  Cases  have been described in which
the effusion was confined to one of the lateral ventricles.   This
I have not  seen, and it is probable that  it could  only  take
place in consequence of the obliteration of the  communicat-
ing opening.  In quantity, the fluid varies from a few drachms
to eight or ten ounces, or more.  As to quality, it is some-
times limpid, sometimes bloody, and sometimes  turbid, con-
taining shreds of flaky matter.  In some cases it is seen in the
ventricles exhibiting all the sensible qualities of pus.   Gene-
rally, however, it seems to contain but a very small proportion
of animal matter.   In the experiments of Dr. Marcet, a thou-
sand grains yielded less than two  grains of animal matter,
which consisted of muco-extractive with a trace of albumen.
In other cases, however, it  is coagulable,  and the truth seems
to be, that it varies exceedingly, both in the quantity and in
the quality of the animal matter which is  contained in it.
   III. By Deposition of False Membrane.—This arises  from
inflammation of the membranous parts, and it may be  found
betwixt the bone  and the  dura mater, or  betwixt  the dura
mater and  the arachnoid.   But  the most  common  seat  of it
is under the arachnoid, where it  is  often  found of great ex-
tent, communicating a yellow colour to  a  great part of the
hemisphere.   In some cases it is found following the course
of the arachnoid alone, or dipping  slightly betwixt the convo-
lutions by small triangular  projections ; in other cases, it fol-
lows entirely the course of  the pia  mater, producing complete 
terminations.                .   17
adhesion of the convolutions to each other.  It is occasionally
found within the ventricles, covering the surface of the cho-
roid plexus ;  and a very common seat of it is the upper sur-
face of the  tentorium.
   IV.  By  Suppuration.—A thin, uniform layer of puriform
matter is often found under the  arachnoid, and occasionally
between the arachnoid and the dura mater, and between the
dura mater and the bone.   It is  also  met with  in  distinct
small cavities formed by partial adhesions  of the membranes
to the bone or to each other, and it  is occasionally found  in
the veiftricles.  But the principal seat  of purulent matter is
in the substance of the brain; and here either it is met with
in distinct defined abscesses, lined by soft cysts, or an exten-
sive portion of the cerebral substance  is found  in a broken
down corrupted state, in which, without any well-defined ca-
vity, pus is  found mixed with the disorganized cerebral mat-
ter.  The cerebellum is a frequent seat of abscesses, and they
may be found of small size but well defined in the centre of
any of the more minute parts, as in the medulla oblongata, or
the pineal and pituitary glands.  An example will be given
of a well-defined abscess, no larger than a small bean in the
substance of the corpus striatum.
   V. By Ramollissement.—This is a disorganization or soften-
ing of the brain, which has now received that name,—a term
adopted from the French to express  the peculiar morbid ap-
pearance ;  and I retain the French  name, to distinguish this
very peculiar disease from slight  degrees of softening of the
substance of the brain, which are often  met with, but which
do not constitute this affection.   It  consists in  a part of the
cerebral substance being broken down into a soft pulpy mass,
like thick cream, or custard,—retaining its natural colour, but
having lost  its cohesion and consistence.  It  differs entirely
from suppuration,  having neither the colour nor the fetor  of
pus; but the  white parts of the brain  in which  it is most
commonly observed retain  their pure  milky  whiteness.   It
may be found in.any part of the brain ;  but the most common
seat of it, in my observation, is the dense white matter forming
the corpus callosum, fornix  and  septum  lucidum.   The  sep-
tum is generally found in such cases perforated by a ragged
irregular opening, and the fornix has either entirely lost both
its figure and its consistence, or retains  its figure  while it is
left untouched, but falls down  into a soft pulpy mass, when
the slightest attempt is made to raise it. 
18             inflammatory affections.
  When I formerly endeavoured to  contribute something to
the pathology of this remarkable affection, I had no hesitation
in considering it as one of the results of inflammation of the
cerebral substance.   Since that time, it has been investigated
with much attention, by M. Rostan  and other French patho-
logists, and a different  view of the nature of the affection has
been strongly contended for by these  eminent individuals.
They consider it as an affection of the brain  entirely sui ge-
neris, and M. Rostan, in particular,  seems to look upon it as
a peculiar and primary  disease of the brain, though he admits
it is sometimes the result of inflammation.           •
  From all the facts which are now  before us, in regard to this
interesting affection, I  think we are enabled to  arrive at the
conclusion, that it occurs under two modifications which differ
essentially from each other.   In the cases of M. Rostan, the
disorganization was observed chiefly in the external parts  of
the brain ; it occurred  almost entirely in very old people, few
of his cases being under sixty years of age,  many of them
seventy, seventy-five, and eighty.   It was found in connexion
with attacks of a paralytic or apoplectic  kind, many of them
protracted ;  and was often found combined with extravasation
of blood, or surrounding old apoplectic  cysts.  On the con-
trary, the affection, to which my observations  have chiefly
referred, was found chiefly in the dense central parts of the
brain, the fornix, septum lucidum, and corpus callosum, or in
the cerebral matter immediately  surrounding  the  ventricles ;
and occurred in persons of various ages, but chiefly in young
people and in children.  It took place in connexion with at-
tacks of an acute character, chiefly  the character of acute hy-
drocephalus ;  and it was in  many cases distinctly  combined
with appearances of an inflammatory kind, such as deep red-
ness of the  cerebral matter  surrounding it, suppuration  bor-
dering upon it, and deposition of false membrane in the mem-
branous parts most nearly connected with it.  We  may even
observe in different parts of the same diseased mass, one part
in the state  of ramollissement, another  forming an abscess
while a third  retains the characters of  active inflammation
 and probably exhibits, as we trace  it from  one  extremity  to
 the other, the inflamed state passing gradually into the state
 of softening.   Remarkable examples of this will be given in
 the sequel, and another of  a different  nature,  in  which  an
 opening in the septum lucidum, produced by  the  ramollisse-
 ment,  was entirely surrounded  by a  ring of inflammation. 
TERMINATIONS.                   19
This is the affection which I have endeavoured to investigate,
and which I consider as one of primary  importance in the
pathology  of  acute  affections  of  the brain,  and upon the
grounds now shortly referred to, I cannot hesitate to consider
it as a result of inflammation.
  When we compare the facts now alluded to,  with  the ob-
servations of M.  Rostan and his  friends, I  think we may
arrive at a principle by which the apparent difference  may be
reconciled.  The principle to which I refer is, that this pecu-
liar softening of the cerebral matter is analagous to,gangrene
in other parts of the body ; and that like gangrene  it may
arise from two very different causes, inflammation  and failure
of the circulation from disease of the arteries.  The former I
conceive to be the origin  of the affection which I have de-
scribed,  and the latter to be the  source  of the appearances
described by M. Rostan.   If this  doctrine be admitted, the
difficulty is removed ; and I do not see any good objection to
it.   Gangrene from inflammation is familiar to every one ; and
equally  familiar, though very different in its origin  and con-
comitant symptoms, is gangrene from disease of the  arteries
of any particular part of the body.   Ossification of the arte-
ries of the brain to a very great extent is a common appear-
ance in elderly people, and seems  to be a very frequent source
of apoplexy with extravasation of blood, at advanced periods
of life.   It appears  extremely  probable that it may  be the
source of,that particular condition of a part of the brain which
terminates in ramollissement of M. Rostan, and indeed  he
distinctly points at this explanation of it.   On the other hand,
I  am still disposed to  contend,  that the ramollissement  of
young persons, occurring in acute affections^ and seated chiefly
in the central parts, is one  of the terminations of inflamma-
tion in  that particular structure.  I conceive it to be an affec-
tion of primary importance in  the pathology of acute affec-
tions of the brain, and to  mark a peculiar seat of inflamma-
 tion of very frequent occurrence.   It is often  combined with
 suppuration in other parts of the  brain, and  very  often with
 effusion in the ventricles ;  but  the peculiar  interest  of it is
 observed in those cases, in which it  is the only "morbid  ap-
 pearance, and in which it is sometimes of small extent.   Of
 this some remarkable examples will be given in the sequel, in
 which the perforation of the septum lucidum,  by  softening a
 part of  its substance, and similar  softening of the fornix, were 
20
INFLAMMATORY AFFECTIONS.
the only morbid appearances in cases which  were fatal with
all the usual symptoms of acute hydrocephalus.
  VI. As terminations of the disease in a chronic form, we
still have to remark thickening of the membranes, contraction
and obliteration of the sinuses, caries of the bones, and some
other affections of the external parts, which will be more par-
ticularly referred to in the sequel.

  In the pathology of acute  hydrocephalus, we  may consider
it as probable, or almost ascertained, that the serous effusion
is only one of the terminations of that inflammatory condition
of the brain, which is a great and leading object of attention
in the pathology and the treatment.  Some  of  the other  ter-
minations are scarcely less frequent; particularly the remol-
lissement of the central parts, which is sometimes met with as
the only morbid appearance, and is found  combined with the
effusion in a very large proportion of the ordinary cases of hydro-
cephalus.   Other  cases,  in  which the  symptoms closely re-
semble those of hydrocephalus, will be found to terminate by
the undefined suppuration, or by this combined with serous ef-
fusion, with the ramollissement of the central parts.   In fact,
we do not often meet with any one of the terminations uncom-
bined, and it is impossible to anticipate from the symptoms,
in what manner  the  disease may terminate in  any particular
case.  Serous effusion, uncombined with any ether  morbid
appearance, I have usually observed in  that which I have de-
scribed, as the fourth form of the disease, in which the symp-
toms are slow and insidious in their progress, and at no period
exhibit much activity.   In the cases of this kind in which the
pain is  more  severe, and the symptoms  are more violent, I
have generally found either effusion  combined with the ramol-
lissement of the central parts, or undefined suppuration.   In
that  which I have described  as the second form of the disease,
I have generally observed the encysted abscess  or the deposi-
tion  of false membrane between the arachnoid and pia mater.
But  these  results  are by no means untform;  and the ramol-
lissement in particular may  occur with very slight and insidi-
ous  symptoms.   The various terminations, indeed, are very
often combined  together,  and all of them are generally com-
bined with more or  less of  serous  effusion.  On what these
varieties depend,  is at present in a great measure  matter of
conjecture.   There is some  reason to believe, that the darker
or cortical parts  of the brain are the chief seats of suppuration 
           INFLAMMATION OF THE DURA MATER.         21

and that the inflammation of the more central white matter
terminates chiefly by ramollissement.  The disease is  also
greatly modified by the activity of the inflammation, depend-
ing probably upon the constitution of the patient.   Thus,  in
some cases,  we find it assuming the highest characters of ac-
tive inflammation ; in others, consisting of the pure scrofulous
inflammation with the lowest degree of activity;  and in others,
forming numerous modifications by which  these two extreme
forms pass  one into another by almost insensible gradations.
Without attempting any general conclusion on  these points, I
shall proceed to describe a selection of cases calculated to  il-
lustrate the various modifications of inflammation of the mem-
branes and of the substance of  the brain.
                      SECTION III.

          INFLAMMATION OF  THE DURA MATER.

  Idiopathic inflammation of the dura mater is a very uncom-
mon affection; the following is  the only distinctly marked case
of it that has occurred to me.

  Case I. A lady aged 22, in the  evening of 16th March,
1820, was suddenly seized with severe pain in the left temple ;
I saw her for the first time on the following morning, when I
found the pulse about 100, the tongue white and moist; some
pain continued in the left temple, but it was not severe ; and
her whole appearance corresponded with that of mild continu-
ed fever, though with some characters of an affection of the
brain.  After  general and topical bleeding, with purgatives,
&c, she was very much relieved; she occasionally complained
of pain in the head,  but at other times was entirely free from
it, and mentioned only a  feeling of confusion.  The pain when
present was occasionally referred to the left temple, and at
other times, was more general, extending over the upper part
of the head.   Amid  these changes, the  first week of the dis-
ease passed, with much of the character of continued fever ;
the tongue white, the pulse varying from 96 to 110, the  nights
sometimes quiet, and sometimes restless.   In the beginning 
22         INFLAMMATION OF THE DURA MATER.
       of the second week, a swelling appeared in the left upper eye-
       lid ; her look was now more oppressed, the pulse varying from
       96 to 120;  the pain varying as before, sometimes a good deal
       complained  of and sometimes  quite gone;  and one day she
       complained of acute pain in the right ear.  On the 27th, she
       began to have severe  shiverings, followed by heat and perspi-
       ration, for which an eminent physician  ordered her the bark in
       large doses.   For two days after this she seemed much better,
       the pulse from 90 to 96, and every symptom greatly relieved.
       The swelling on the left eyelid was punctured, and discharg-
       ed a good deal of purulent matter; and a probe introduced by
       the opening passed to a great depth along  the upper part of
       the orbit, where the bone  in some places felt bare.  On  the
       evening of  the  29th, she was seized with slight convulsion,
       but it soon  subsided,  and  after it she seemed quite  as well as
•      on the two  preceding days, all the previous symptoms being
       very much relieved.  On the 30th, there was more complaint
       of headach, with an oppressed look, and the pulse varied  ex-
       ceedingly, being sometimes very rapid, and at other times  a
       little above the natural standard.   On  the 31st, there was no
       particular change ;  she was quite intelligent, and all her senses
       were entire.  When  she was last visited, about nine o'clock
       at night, she complained of some uneasiness across  the crown
       of the head, but no other change was remarked in the symp-
       toms.  Between one and two in the morning, she was observ-
       ed to  be slightly incoherent, and soon after sunk into a state
       of lowness; did not speak, but seemed quite sensible, and
       died at three.   Very  slight delirium had been observed on  a
       preceding night, about the 28th, and once she had complain-
       ed of dimness of sight, but none of these symptoms had been
       again taken notice of.
          Inspection.  On  raising the skull-cap a good deal of puru-
       lent  matter escaped, which  had been collected betwixt  the
       bone  and the dura mater.   The space in which it had been
       contained was defined by an irregular elevated  margin of  ad-
       ventitious membrane, by which the dura mater had adhered
       to the bone, the included  space  being  about the size of  a
       crown piece: it was on the anterior part of the right hemi-
       sphere.   The dura mater  included within this space was  de-
       pressed ; its surface  was  in some places ulcerated  and in
       others black, but the  membrane was quite entire, and  the
       bone was sound.   On  raising  the dura  mater, the inner sur-
       face of this portion had the same irregular, ulcerated appear- 
IDIOPATHIC.                     23
ance as the outer surface, and when  held up to the light, the
membrane at the part appeared to be in some  places conside-
rably thickened, in others very thin.   The right hemisphere
of the  brain, over all that part of it which is usually exposed
in the  ordinary way of opening  the  head, was covered by a
thin uniform  layer of very thick  purulent matter, spread over
it with great equality, and this  being removed, an extensive
stratum of adventitious membrane was found under the arach-
noid.  It was irregular in thickness, being most remarkable
on  the anterior part of the hemisphere, and disappearing on
the posterior  part.   It  followed the course of the arachnoid,
covering the openings of the convolutions, but not dipping
between  them.   The pia mater betwixt the convolutions was
highly vascular, but without any deposition.   On cutting into
the substance of the right hemisphere, the cerebral matter was
to a slight depth of a dark livid colour, but without any change
of  structure.   There was no  effusion in the ventricles, and
the  brain in all  other respects was quite healthy.  The sup-
puration  in the left orbit  was confined to a cavity betwixt the
orbit and the ball of the eye, without any disease of the bones,
and without  any internal disease  on that side of the cranium.
   In this remarkable case, the inflammation of the dura ma-
ter appears to  have been the primary disease,  though it was
afterwards complicated  with  extensive inflammation of the
 arachnoid.   The only case which I have met with in  any de-
gree analogous to it, is one which is mentioned by M. Fizean,
though it differs from it in being  complicated with disease  of
the bone.*   A boy aged 15, had a "fluxion" of the  right
cheek and pain of the teeth.  After some days it ceased, and
removed to the left side of the head, where it occupied entire-
ly the  eye and its  dependencies.  He then had irregular at-
tacks of fever, with want of  sleep and loss of appetite, and
about the 7th day considerable delirium, frequently attempting
to  get out of bed.  On the 8th day, the left eyelid was swell-
ed so as to close the eye, and on raising it  the eyeball ap-
 peared unusually prominent.   He  had nausea  and severe
 headach, but was quite sensible, and the fever was moderate ;
 some delirium  occurred towards  night, and the  swelling ex-
 tended beyond the eyelids over  the forehead.  On  the 9th
 day, there was permanent delirium ;  on the 10th, coma and
 death.   The left  eyelid and  the integuments of the left side
* Journal de Med. torn. xi. New Series, p. 523. 
24         INFLAMMATION OF THE DURA MATER.
of the forehead were imbued with purulent matter; the frontal
bone was denuded and carious for a considerable space ;  the
abscess penetrated the orbit, and pus was found in the upper
and back part of it, where the bone was also denuded.  The
caries of the frontal bone occupied the whole thickness of it,
and extended in  length  somewhat  beyond the roots of  the
hairs, and transversely from the external orbitar process be-
yond the nose.  The dura  mater was detached and  covered
with pus over a  space corresponding with the external disease,
but it was not detached from the superior part of the vault of
the orbit.   The arachnoid was covered with purulent matter;
there was  very  little  fluid in the ventricles, and the brain in
other respects was healthy.
  The following case, described by M. Prathernon, is referred
by M.  Gendrin  to the head  of inflammation  of the dura mater.
A man aged 62,  had violent pain  in the upper part of the
head, which suffered remissions.  When he was first visited,
this had continued five days;—there was  then considerable
torpor, with weakened  memory, and some confusion of ideas,
but no fever.—Under the usual treatment, the symptoms went
on for a fortnight, with little change, unless  that there were
attacks of fever, and gradual loss of strength.  The symptoms
then assumed an intermitting character, and were treated with
quinine.   This  did not agree, but soon after, an improvement
took place in all the symptoms: the pain was  much diminish-
ed, the man was  out of  bed, recovered  his appetite, and ap-
peared to be in all respects better.  A few  days after this, he
complained of extreme weakness, and suddenly expired. The
whole duration  of the case was about a month.   On punctur-
ing the dura mater, turbid  fluid tinged with blood  was  dis-
charged  to the amount  of about a pound, and  there were
some clots of blood lying on the surface of the  brain and be-
tween the lobes.   The dura mater was in some places thick-
ened to the extent of two or three lines, especially at the part
corresponding  to  the principal seat of the pain.  Its inner
surface was of  a deep  red  colour, rugose and unequal,  with
adhesion to the arachnoid.   The arachnoid also was thicken-
ed and opaque  on the upper part of the hemispheres.
   These are the only cases that I am acquainted with of idio-
pathic inflammation of the  dura  mater  taking  place  in  this
manner;  but the  disease is frequently met with in  another
form.   It occurs in connexion with affections of  the ear and
 of the petrous portion of the temporal bone. 
          CONNECTED WITH DISEASE OF THE EAR.       25

  This insidious and highly dangerous affection generally be-
gins with pain in the ear, and for some days may be consider-
ed merely as  a common  earach.   Sometimes discharge of
matter takes place from the' ear, which is expected to relieve
the pain; but the pain continues or  becomes  more violent.
The patient becomes oppressed and drowsy, then slightly de-
lirious, often with shivering, and  at last comatose.   In other
cases, there is no discharge of matter, but the patient, after
complaining for a day or two of deep-seated pain in the ear,
becomes restless and forgetful,—lies rolling his head from side
to side, or tossing  about  his arms, and in a short time sinks
into coma.  In other cases, again, the affection supervenes
upon the sudden cessation of a purulent discharge from the
ear, which perhaps  had been of some standing; such as that
which often follows scarlatina.  The sudden disappearance of
the discharge  in these cases, is  followed  by pain in the ear,
this by languor and drowsiness, and in a few days by coma.
The pulse is in some cases frequent, in others natural, and in
others below the natural standard.  The nature of this disease
is illustrated by dissection.  There is generally caries of the
pars petrosa  of the temporal  bone, sometimes confined  to a
small  spot of it.  A portion of the dura mater corresponding
to this part is  inflamed and thickened, spungy,  or ulcerated,
and generally detached from the bone.   Between it and the
arachnoid, there is commonly a deposition either of  purulent
matter,  or of  false  membrane, and this deposition, sometimes
extends along the tentorium.   In some cases there is a super-
ficial  abscess  of the brain itself, or of  the  cerebellum, often
with effusion  in the ventricles, and the other usual marks of
general disease in the brain.  Matter is also frequently found
in the cells of the petrous portion, in the canals of the ear, and
in the cavity of the  tympanum, and sometimes it extends into
the cells of the mastoid process.
   This  disease will be illustrated by the three following cases,
the third of which is valuable from showing the disease in an
intermediate stage of its progress, the fatal event having taken
place from another  affection.

   Case II. A gentleman aged 20, on the 20th January 1820,
complained of violent toothach, seated in  a tooth on the right
side of the upper jaw.   On the 21st, the pain extended to the
ear, without any other symptom.  On the 22d, the pain con-
tinued in the ear,  and extended toward the temple.   He lay
                             4 
26         INFLAMMATION OF THE DURA MATER-

in bed part of the day, but got up afterwards.  Leeches were
applied, and he took some laxative medicine, which he vomit-
ed, and he had afterwards repeated vomiting.   On the 23d, the
pain was more general over the head and across the forehead,
with some vomiting, and in the evening he had shivering.   In
the night he became incoherent and delirious ; he was then seen
by a surgeon, who found him considerably incoherent, but com-
plaining of severe headach; the pulse70 and of moderate strength.
I saw him on the 24th ; his pulse was then sixty, his face rather
pale; the  headach continued, and was chiefly referred to the
forehead; his look was vacant; he answered questions distinct-
ly when he was roused, but talked incoherently when his atten-
tion was not kept up.   He was now treated by repeated general
bleeding, which he bore well; cold applications, blistering, pur-
gatives, &c.  On the evening of the 24th, there was considera-
ble  shivering.  On the 25th, there was less complaint of pain,
but  more  incoherence,  and  a tendency to stupor, pulse from
60  to 70.—26th,  Pulse from 100 to 120.—27th, and 28th,
Little change; answered questions when roused, but when
not  spoken  to, lay either in  an oppressed state, or talking in-
coherently;  pulse  varying from 96  to  120.   On  the  28th
there was some discharge of fetid matter from  the right ear.
29th, Constant incoherent talking, pulse 96, of good strength;
the right eye was suffused, the ball of it appeared turgid and
enlarged, and the corner was covered with a yellowish  slough.
In the course of this day, the mouth was at times  observed to
be drawn  to the left side, especially when  he was drinking.
At night he began to  sink, and died at five in the morning of
the 30th.
  Inspection.—There  was some  effusion under the arachnoid
on both hemispheres ;  much effusion in the ventricles, and ex-
tensive ramollissement of the septum lucidum, the fornix, and
the  cerebral matter bordering upon  both  lateral ventricles.
There was extensive caries of the right temporal bone ;  behind
the ear on the thin part of the bone it was very dark-coloured
and the petrous portion was dark-coloured, very soft, and when
cut into, discharged matter from its cancelli and from  the ca-
vity of the ear; the dura mater corresponding to the temporal
bone was much thickened.  The part of it which  lay anterior
to the petrous portion  was in a  state of  recent inflammation ■
the part behind the petrous  portion was much thickened and
spungy; and between it and the bone there was a deposition
of thick purulent matter.  From this  place  the disease had 
          CONNECTED WITH DISEASE OF THE EAR.        27

spread along the tentorium, and over nearly the whole surface
of the cerebellum, on almost every part of which there was a
deposition of coagulable lymph, with thick flocculi of purulent
matter; this was most abundant on the tentorium, and on the
right and posterior parts of the cerebellum, and it was traced
into the fourth ventricle.  Under the cerebellum there was a
considerable quantity of pus, and in its substance there was a
small  abscess in the posterior part betwixt the lobes.

  Case III. A girl aged 9,  had been liable to attacks of sup-
puration of the ear, which were usually preceded by severe
pain and some fever.  She suffered one of these attacks in the
left ear in July  1810, from which she was not relieved, as for-
merly, when the discharge of matter took place, but continued
to be affected with pain, which  extended over  the  forehead.
In consequence of this, I saw her, for the first time, on the day
on which the discharge took  place, and found her affected with
pain across the forehead, impatience of light, and some vomit-
ing ; her look was oppressed, and the pulse 84.   Bloodletting,
purging, blistering, and  mercury, were employed without  re-
lief.   On the second day, the pulse was 60; on the  3d, there
was slight and transient delirium,  a degree of stupor, and
slight convulsions.   She complained once or twice of pain in
the back of the head, but her chief complaint was  always of
the forehead.   She lay constantly with both her hands pressed
upon her forehead, and  moaning from  pain, of which there
had not been the least alleviation;  4th day, pulse from 80 to
86; no change in the symptoms;  oppression, but  no coma:
5th day continued sensible, and died suddenly in the afternoon,
without either  squinting, blindness,  or coma,  and  the pulse
having continued  under 90.  The left ear had continued to
discharge matter, and an opening had formed behind the ex-
ternal ear, from which also there was a purulent discharge.
  Inspection.—A considerable quantity of colourless fluid was
found in the ventricles of  the  brain.  The brain  in other  re-
spects was healthy.  In the left lobe of the cerebellum there
was an abscess of considerable  extent,  containing purulent
matter of intolerable fetor.   The dura mater, where it covered
this part  of  the cerebellum, was thickened and spungy, and
the bone corresponding  to this portion was soft and slightly
carious on its inner surface; but there was no communication
with the cavity of the ear.   The opening behind the  ear mere-
ly passed behind the external ear, and communicated with  the
external meatus. 
28         INFLAMMATION OF THE DURA MATER,

  Case IV. A young  lady aged 15, had been liable, for six
or seven years, to attacks of pain in the right ear, followed by
discharge of matter, but she had been free from any of  these
attacks for  some time previous to the illness which forms the
subject of the following history.  On  the 25th of April 1822,
she  complained of cold  shivering through the day, and in the
evening had  headach with pain in the right ear, and  these
symptoms continued on the following day.   On the 28th, she
was seen by Mr. Brown, who found her with quick pulse and
foul tongue, severe pain in the ear, and slight headach.  On
the  29th, some discharge took place from the ear, but without
relief of the pain, which continued with violence on the follow-
ing day.  On the 1st of May,  the pain was somewhat abated
in the ear, but had extended over the right side of the head;
pulse frequent;  general and topical blood-letting were employ-
ed with partial relief.  L saw her on the 3d :  the headach was
then rather  abated ; the pulse was frequent and weak; she had
a pale  unhealthy aspect, and a look of oppression, bordering
upon coma.   The pain was chiefly referred to the parts above
and behind the right ear, where the integuments were painful
on pressure, and at one spot near the mastoid process, felt soft
and elevated;  a puncture was  made at this place with a lan-
cet, but nothing was discharged.   Topical bleeding, blistering,
&c, were recommended.  (4th) Pulse in the  morning  148,
in the  course of the day it fell to  84,—look  of much languor
and exhaustion.   (5th) Dark-coloured matter of intolerable
fetor began to  be discharged  from the puncture which had
been made  behind the ear.  The opening here was  enlarged,
and a  probe  being introduced, the bone was felt  bare and
rough  over a  considerable space; headach much relieved,
pulse natural.   (6th) Great discharge from the opening,  head-
ach much  relieved, pulse  112; complained  of some pain  in
the left side of the thorax, and  there was considerable  diar-
rhoea.   (7th) No headach; there was much discharge of fe-
tid  matter from the opening  near the mastoid process,  and a
probe introduced by it, passed backwards and downwards un-
der the integuments  of the  neck  as  far as the spine.   (8th)
Pain in the thorax continued,  and was now so  urgent that a
small bleeding was employed with partial relief; it could not
be carried  farther on account  of her  increasing weakness__
pulse 140.   (9th) Said she felt better, and made no complaint
of pain—pulse very rapid, and strength sinking—died on the
 10th. 
          CONNECTED WITH DISEASE OF THE EAR.       29

  Inspection.—Every part of the brain was in the most healthy
state, except a small portion on the right side  near the ear,
which was of a  dark leaden colour; the tinge,  however, was
found to be entirely superficial.  The right temporal bone, ex-
ternally, was bare  through a great part of its extent; internal-
ly, it was  in many places rough and dark-coloured, and there
was some  dark-coloured matter betwixt it and the dura mater.
The  dura mater  at  this place was for a considerable space
thickened, spungy, and irregular;  the coats of  the right late-
ral sinus were considerably thickened through  its whole ex-
tent, and the capacity of the sinus was very much diminished,
by a deposition similar to that which  occurs in the cavity of
aneurism.   The internal ear contained dark-coloured matter.
The left cavity of  the pleura contained fully a pound of puri-
form fluid;  the left lung; was collapsed, dense, dark-coloured,
and covered by a coating of coagulable lymph.

   These examples will be sufficient to illustrate this insidious
and  dangerous affection; several  analogous cases are  men-
tioned by Itard, but they do not present any important varie-
ties  in the  phenomena.   One of  them was complicated with
extensive swelling of the  parotid, and the  side of the face ;
there was deep-seated  lancinating pain in both ears, and the
case was  fatal by coma in  eight days.  There  was much pu-
rulent matter in the internal ear and in the Eustachian tube,
with inflammation and thickening of the dura  mater, and co-
pious deposition betwixt it and the bone.*   The  termination
of this affection by  coma is sometimes sudden  and unexpect-
ed :  I lately saw a gentleman, about seventy years of age, who
had been keeping the  house  for a few days, on account of a
dull uneasiness in one ear; it was referred to a space, which
he defined by planting the points of his fingers  round the ear,
so as to  include a space of about three inches in diameter.
There was no constitutional disturbance, and no  danger was ap-
prehended,  until one morning he was found in a state of perfect
coma, and died in the afternoon.  He was moribund when I saw
 him, and no examination of the body was  obtained, the case
 being at a distance  in the country.  The affection may be also
 suddenly fatal without coma.  A young man mentioned by Dr.
 Powel,f who had been liable to  suppuration  of the ear and
 deafness, was seized  with deep-seated pain in the right ear
 without fever.  Relief was obtained from opiates, but the pain
* Itard, Traite des Maladies de 1'Oreille.
t Transaction* of the College of Physicians, vol. v. 
30         INFLAMMATION OF THE DURA MATER,
continued, with a fetid discharge.  On the  10th day of the
disease, after a violent paroxysm of pain, he sunk rapidly and
died.   The  pars petrosa was found  black and  carious; the
dura mater corresponding to it was black,  sloughy, and sepa-
rated from the bone; and under the  dura mater there was a
collection of pus and coagulable lymph, amounting to several
ounces, which covered the whole superior surface of the right
hemisphere.   Mr. Parkinson* mentions a boy, aged fourteen,
who had been affected for two months with headach, and  dis-
charge of matter from the right ear;  a week before his death
the pain increased, and was accompanied by great  debility,
giddiness, and some vomiting.   He continued  in this state
without stupor, or any other remarkable symptom, until the
day of his death, when  he was suddenly seized  with convul-
sions, and died.   An abscess was found in the middle lobe of
the right hemisphere of the brain, and  another in the cerebel-
lum.   There was extensive caries of the pars petrosa, with
effusion in the ventricles to the extent of three ounces.
   This affection occurs  most frequently in persons who have
shown a tendency to disease of the parts, by purulent discharges
from the ear, or deep-seated suppuration behind the ear.  A
very unmanageable  abscess is often met with in this situation,
from which  a probe can  be passed to  a great depth into the
cells of the mastoid process.   It is generally a scrofulous af-
fection, extremely tedious in its progress,  and sometimes ter-
minates fatally, by inflammation spreading to the dura mater.
   The  matter which is formed in these affections, whether it
be in  the substance  of the brain or  betwixt  the membranes,
sometimes finds a vent by the ear, the  dura mater being ulce-
rated, and the bone perforated  by the caries ;  and in this way
alarming symptoms are sometimes unexpectedly relieved.  The
relief indeed is in general but temporary: the patient continues
liable  to pain, followed  by discharges from  the ear, and at
last dies comatose, often with gradual abolition of the faculties,
tremors or general convulsions.  In  some cases  of this kind,
there is reason to believe that a communication had existed
for a length of  time betwixt  the ear  and a diseased cavity
within the cranium, and that the discharge thus afforded to
the matter from time to time, had retarded the fatal event.  In a
boy,  mentioned by Mr.  Brodie, there was in the left hemi-
sphere of the brain a cyst about three inches in diameter con-
taining thick  dark-coloured pus; the  lower part of it rested
* London Medical Repository, March, 1817. 
CONNECTED WITH DISEASE OF THE NOSE.       31
Upon the petrous portion of the temporal bone, and there was
an opening through  the cyst, dura mater, and bone, forming
a free communication betwixt the cavity of the abscess and
the meatus auditorius  externus.*   Examples, indeed,  have
oecurred which would  lead us to suppose, that in some such
cases the relief is permanent.   A young lady in Edinburg,
several years  ago, after  the usual symptoms in the head, had
Iain for three  or four days in a state of perfect coma, and her
situation was considered as entirely hopeless.  Her medical
attendants, paying their visits  as a matter of form, were as-
tonished to find her one day sitting up and free from complaint;
a copious discharge of matter had  taken place from the ear
with immediate relief,  and she continued in good health.   It
is, however, by no means certain, that in such a case as this
the discharge came from the cavity of the cranium ;  for  there
is reason to believe, that extensive suppuration within the ca-
vity of the tympanum is  capable of producing symptoms  of
  treat urgency, especially if there  should  be any difficulty  of
  nding an outlet.  In a case of this kind by Itard, the matter,
after urgent symptoms, escaped by the Eustachian tube, and,
by constantly dropping down in that direction, produced cough
and  great irritation  of  the larynx; after partial relief in this
manner,  the  symptoms in the  head  and in the  ear returned,
and were at length relieved by the puncture of the membrana
tympani.
   A disease, analogous to that now described, sometimes oc-
curs in the nose.   A. person who  has  been  liable to pain  in
the forehead, and purulent discharge from the nose, becomes
at last forgetful and  delirious, and dies comatose.  The eth-
moid bone is found carious, the dura mater corresponding  to
it is diseased, and there is a deposition of pus betwixt it and
the brain, sometimes an abscess in the brain itself.   Several
cases of this kind are mentioned  by Lieutaud and Bonetus. *
Morgagni  mentions a  priest who, after  being affected with
fever, delirium, pain in the forehead, and convulsions, fell into
coma, from which  he was relieved  by discharging  purulent
matter from  the  nose.  A similar case, in a girl of fourteen,
is mentioned by Mangetus.   We are not, however, to con-
clude with certainty, that in these cases the discharge of matter

  * Transactions of a Society for the improvemeBt of MedjcaJ and Surgical Know-
ledge, vol. iii. 
32         INFLAMMATION OF THE DURA MATER,
 was from the cranium, as violent symptoms of the same kind
 have been known to occur from suppuration in the frontal si-
 nus.   This generally discharges itself by the nose, and  the
 cases do well; but a case is related  by Richter,* in which a
 suppuration within the frontal sinus burst into the cavity of the
 cranium and was fatal.    In other cases it makes its way out-
 wards through the frontal bone, leaving a fistulous opening,
 which continues  to  discharge  matter  for a considerable time
 before it  heals.   Some  cases  are also  on record, in  which
 worms in the frontal sinus were the source of alarming  symp-
 toms, which were relieved by the discharge of them.f   In  one
 of these, by M.  Littre,  there were violent convulsions.  Dr.
 Bright has described a case in which  the lining membrane of
 both frontal sinuses was  extensively ulcerated, and an opening
 had  taken place from the left into the cavity of the cranium.
 The case was complicated with abscess in the anterior part of
 the left hemisphere, but the symptoms seem to have been very
 obscure,—being chiefly those  of continued fever, during re-
 covery from which there was discharge of blood and pus from
 the nose.  This was followed by symptoms of cerebral disease,
 ending in coma.

    It is foreign to my plan to enter upon those important cases,
 in which the dura mater becomes inflamed in connexion with
 disease of the bone, arising from external injuries, and maybe
 productive of symptoms analogous to  those already mentioned.
 Some years ago, a remarkable case  of this kind occurred in
 Edinburgh, in a middle   aged man, who, after a short illness,
 died in a state of coma.   In opening the head, a collection of
 matter was found under  the  temporal  muscle, which commu-
 nicated, through a carious  perforation of the temporal bone,
 with an  abscess in the substance of the brain.  Burserius
'•mentions a woman who, after  suffering for a fortnight severe
 pain in the left side of the head, was sized with swelling and
 inflammation on the left eyebrow, eyelids, and cheek.  After
 several days, the swelling suppurated and discharged much
 matter, and the left eye was found to be blind; after a few
 days more, she was seized with convulsions, and died coma-
 tose.  On dissection, the external suppuration was found to
 have penetrated to the bottom of the orbit, betwixt the bone
 and the ball of the eye, without injury of the ball itself- inter-
   * Observat. Chir. Fas. 2d.
   t See Hill's Cases in Surgery, and Hist, de l'Acad. de Science for 1708__33. 
WITH CARIES  OF THE BONES,  &C         33
nally there was an extensive collection of matter, which com-
municated freely with the cavity of the orbit.
  In some cases of this kind, the trephine has been applied
with success;  and  they have shewn what extent of disease
within the cranium may be recovered from, when a free out-
let is given to the matter.  Morand mentions a monk who had
been for some time affected with dicharge of matter from the
right ear, with  violent pain extending  over the whole right
side of the head.   A tumour formed behind the ear, extending
towards the  temple, which, being opened, was found to be an
abscess,  and a probe could  be  passed from it,  through a ca-
rious opening, into  the cavity of the cranium.  The trephine
was applied at this place, and discovered a suppurating cavi-
ty within the cranium, which discharged a teacupful of mat-
ter ; the discharge diminished gradually, and the  sore was heal-
ed in  two months.*   M. Roux  describes the case of a boy,
aged thirteen, who, after a blow on the back part of the head,
had a  fistulous opening,  which  discharged  matter for four
years.  He was liable to  attacks  of drowsiness and oppression
in the head ; and these were  generally relieved by copious
discharges of matter from this  opening, which was found to
perforate  the bone.   After various  treatment, the trephine
was at length  applied, when  a small ragged opening was
found in the dura mater, which led to a cavity under it, dis-
tinctly bounded by an adhesion between  the dura  mater and
the arachnoid ; it discharged at the first  opening about three
ounces  of matter, and  the  case terminated favourably,  the
parts  being  healed in about two months.f
  The dura mater appears to be much less liable to idiopathic
inflammation than the other membranes of the  brain.   Vari-
ous cases, however, are on record, in which it was affected to
a considerable extent, without any disease of the bone.   In a
case  of long-continued headache,  mentioned by Pawius,
which terminated by convulsions, the  dura  mater under the
sagittal  suture  was found eroded and  perforated;  there was
also an abscess in the cerebellum.  Rumlerus found the dura
mater  eroded in several places, in  a young man  who died
comatose and convulsed.  Several cases of the  same kind are
mentioned in the Miscellanea  Curiosa; and  Haller found in
several instances, the falx eroded by large openings, and the

  *  .Morand Opuscules de Chirurgie.   \ Nouveau Journal de Medicine, tome xn
                           5 
34         INFLAMMATION OF THE DURA MATERJ
hemispheres of the brain at these places adhering  to each
other.
  As a result of inflammation of the  dura mater, a circum-
stance  occurs  in  Case  IV., which is worthy of notice, and
which I think has hitherto been little attended to ;  I mean the
obstruction of the  lateral sinus.   Of this affection, I add the
following remarkable example, in which,  though complicated
also  with disease of the bone, this affection of the sinus was
the principal morbid appearance internally.

  Case V.—A young lady, aged sixteen, (3d August, 1816,)
complained  of severe headach,  which  extended  over  the
whole head. She had  an oppressed look,  and great heaviness
of the eyes ; pulse 120 ; the face rather pale.   She had been
liable to suppuration  in the ears, and the  left ear had been
discharging matter for three weeks ; she had  complained of
headach for a fortnight, and had been confined to  bed for two
days.  Bloodletting, purgatives, blistering, &c, were employ-
ed on the third and fourth with considerable temporary relief.
(5th) Headach easier, some vomiting, and  several severe at-
tacks of shivering, pulse  112.  (6th) Pulse  84, headach se-
vere, now confined to the back part of the head ; eyes heavy,
pupils a little dilated ; bleeding from the temporal artery was
employed,  with purgatives, issue, &c.   (7th)  Pulse in  the
morning 84, and  in  the  evening 120;  headach  as before,
with a dull vacant look.   There was a buffy coat on the blood
from the temporal artery.  (8th and 9th)  Pulse from 120 to
140; severe pain of the back of the head  and neck.  (10th
and  11th) Pulse from 130 to 140, considerable  stupor and
occasional delirium, constant complaint of pain in the back of
the head.   (12th) Increase of coma, but was sensible when
roused; answered questions distinctly, and knew  those about
her  until  a few minutes  before  her death, which happened
about mid-day.
   Inspection.—The pia mater was  highly vascular, as if  mi-
nutely injected; the veins on  the  surface of the brain were
turgid, and  at; one place  on the posterior part there was a
slight appearance of extravasation of blood under the pia ma-
ter.  There was no serous effusion, and no disease in the sub-
stance of the brain.  The left lateral sinus was  remarkably
diseased through its whole extent;  when  compressed  it dis-
charged pus, and some thick cheesy matter;  it contained no
blood ; its coats were  much thickened, and its inner surface 
         CHRONIC, WITH REMARKABLE THICKENING.     35

was dark-coloured,  irregular, and fungous; at one part the
cavity was nearly obliterated.  The disease extended into the
torcular Herophili, and affected in some  degree the  termina-
tion of the longitudinal sinus.   Behind the auditory portion of
the temporal  bone,  near the  foramen  lacerum,  and in the
course of the left lateral sinus, a portion of the bone about the
size of a shilling was dark-coloured and carious on the inner
table:  it was at this place that the sinus appeared to be most
diseased. The auditory portion of the bone was extensively ca-
rious ;  the  cells of it were everywhere full of purulent matter,
and communicated freely with the cavity of the ear.
  It may perhaps be doubted whether  the remarkable disease
of the lateral sinus which occurred  in Case IV., was a recent
affection, and what influence it had in producing the symptoms
in the fatal attack.   Pilchard- found  a similar affection of the
sinus in  a woman who had been epileptic for two years, and
died in  one of  the  fits without any previous  change  in her
symptoms.   He describes the left lateral  sinus as being
" through its whole  length  filled up by a substance  very dif-
ferent from a recent coagulum, and apparently consisting of a
deposition  of lymph, which had  become organized.  It ap-
peared so completely to occupy the calibre of the sinus, as to
have entirely impeded the transit of blood through it." There
was no other morbid appearance,  excepting very slight effu-
sion.*   Dr. Bright  found the lateral, cavernous, and petrosal
sinuses of the left side, full of dark ill-conditioned pus, which
also filled the  jugular vein, as far as its junction with the su-
bclavian.  The symptoms were pain in the ear, followed by
much delirium, and extremely restless  nights,  and death after
about three weeks.   A few days before death, there was a co-
pious discharge,  of unhealthy purulent matter from the ear.

  As the result of inflammatory action  of a  more slow and
chronic kind, the dura mater is liable to thickening, and depo-
sition of new matter betwixt its laminae.   The following case
affords an example of a very remarkable  disease which ap-
pears to  to have been produced in this manner.

  Case  VI.—A gentleman aged 60, had been liable for two
years before his  death to  attacks of giddiness, accompanied
by complete loss of all muscular power, in which, if not pre-

           * Prichard on Diseases of the Nervous System, p. 175. 
36         INFLAMMATION OF THE DURA MATER;

vented, he fell to the ground. In these attacks he did not lose
his recollection, and he recovered completely in a few minutes.
Before the commencement of this complaint, he had been lia-
ble to severe pain in the head, and giddiness, the  attacks of
which  generally went off  with vomiting.  He was  sound in
his mind, but had considerably fallen off in flesh and strength;
he felt an unsteadiness in walking which made him afraid of
going alone ; and, for some  months before  his death, he had
perceived an increasing weakness of both his lower extremi-
ties.   On the 1st  of August 1816, he was attacked with hemi-
plegia of the left  side, accompanied by headach and giddi-
ness ;  the  pulse was  natural, and his mind was not affected.
For four days he continued to be affected with the most com-
plete hemiplegia; he then began to recover a little motion of
the parts, and about the 15th, was able to raise his arm to his
head, and to walk a little with assistance ;  he still complain-
ed of giddiness, and noise in his ears, but had little headach.
Bloodletting and the other usual remedies had been employed.
On the 19th, there was considerable headach ;  on the 20th, he
became incoherent; and on  the 21st, fell into  perfect coma,
with some  convulsion.  On  the 22d, he was considerably re-
covered, so as to  know those about him, and to answer ques-
tions rationally ; but at night he relapsed into coma, and died
on the 23d.  For the last three days his pulse had been from
112 to 120.
   Inspection.—Along the upper part of the right hemisphere
of the brain, there  lay a remarkable  tumour  five and a half
inches long, two  and a half broad, and about half an inch in
thickness ; it was formed  by a separation of the laminae of the
dura mater, and a deposition of new matter betwixt them.—
This new matter was, at the posterior part,"  white and firm ;
in other places, especially about the  centre of the tumour, it
was more recent  coagulable lymph, firm, yellow, and semi-
transparent ;  and, at the anterior part, there was a cavity con-
taining  yellowish serous fluid.   The  tumour lay from before
backwards, along the upper part of the hemisphere,—the in-
ner  edge of it being about an  inch  from the falx ; the dura
mater all around  it was considerably thickened, as were also
the coats of the longitudinal sinus.  The surface of the brain
 where the  tumour lay, was  so  depressed as to retain an im-
pression of its figure ; and, on  the anterior part of the brain
the  substance was  considerably softened, with some appear- 
        CHRONIC, WITH REMARKABLE THICKENING.      37

ance of suppuration.   There  was very little  serous  effusion,
and no disease in any other part of the brain.

  For the following very important case I am indebted to Mr.
Adams of Banchory.  It is distinctly referable to chronic in-
flammation of the dura mater; and many of the circumstances
of it  are  exceedingly remarkable,—particularly  the absence
of marked cerebral symptoms, and the  prominent complaints
being entirely referred to the stomach.

  Case VII.—A gentleman  of cultivated mind, and an ama-
teur painter by profession, about 45 years of age, had  always
enjoyed good health, except that,  latterly, he  had suffered
from ulceration of the tonsils. In the spring of the year 1829,
being in London, he felt languid and  depressed,  owing, as
was imagined by himself and his friends, to  too ardent appli-
cation to his professional pursuits ; his  sight became impair-
ed, his stomach  irritable, and he  had various other symptoms
which were referred to a morbid derangement of the hepatic
system.   After being treated for some time upon general prin-
ciples, he came down to the country, towards the end of the
month of June, in expectation that rural retirement would soon
restore him to health.  During  the  three succeeding  months
the principal symptoms of his complaint were,—a torpid state
of the bowels, occasional vomiting without nausea, sometimes,
though rarely, dull headach, impaired sight, false vision, and
ocular spectra.  The spectral illusions  generally consisted of
fantastic  female  figures dancing around him ;  and,  at one
time, he had the impression of being attended by one of them
wherever he went.  He was always sensible, however,  that
they were unreal appearances. He lost strength gradually, his
stomach became more and more irritable, and he died on the
12th of October, excessively emaciated.
   Inspection.—A  portion  of the dura mater,  about  three
inches by two, immediately to the left of the falx,  and a lit-
tle anterior to its termination in the  tentorium,  was sepa-
rated from the skull  by a layer of coagulated lymph, imper-
fectly, or not at all organized, and of a dull yellowish  red  ap-
 pearance.  This portion of the  membrane was glued pretty
 firmly, by the same kind of matter, to the surface of the brain,
there being no trace of pia mater or  arachnoid visible.  This
 part of the brain was much indurated, especially at one point
 anteriorly and to the left, where the induration extended to the 
38         INFLAMMATION OF THE DURA MATER.

depth of  an inch and a half;—it  adhered also  to  the falx,
which was similarly diseased for nearly a square inch through-
out its whole thickness; but did not adhere to the  right he-
misphere of the brain, or involve any part of it  in the disease.
The brain, in the immediate vicinity of  this induration, was
somewhat softened;—every other part of it was sound, except
that there was about a table-spoonful of serum in the ventri-
cles, and as much about the base of the skull.  The stomach
was not examined.
  This case is  a striking example  of  extensive cerebral dis-
ease with very obscure  symptoms.   It also tends to illustrate
the nature of spectral illusions ;  and it is deserving of remark,
as tending to illustrate the shape which these spectral appear-
ances assumed, that about the time this gentleman became ill,
his mind was intent upon making a drawing of one of the fan-
ciful descriptions in Moore's Epicurean,  and by the  writer of
this report, it was always  supposed that the phantoms which
seemed to sport before his eyes, bore some  resemblance to
those  which had formerly occupied his imagination.
  It remains to be mentioned,  that no circumstance in his
life was known to account for the diseased state of his brain,
unless that, about three years before his death,  he met with  a
fall upon a stair, whereby he hurt one of his knees seriously,
and, as was suspected by his relatives, also  sustained some
injury of the head.  This  explanation,  however, is merely
conjectural.

  I have found nothing described  by any writer precisely si-
milar to these  remarkable affections.  The case most nearly
resembling Case VI. in the  symptoms, is one described by
Lancisi.*  The attacks in this case consisted  of  paroxysms,
which appeared to be a mixture of syncope  and apoplexy;
sometimes accompanied with hemiplegia, and sometimes with
convulsion.   The pia mater was found remarkably thickened
and covered with a kind of ill-conditioned pus.   Willis found
a remarkable thickening of the  dura mater at the base of the
brain, in a young woman who had  been liable to severe head-
ach, ^aggravated  at the menstrual period,  and at these times
accompanied by distortion of the neck to one  side; she was
likewise  liable to attacks of vertigo and lipothymia, and died
comatose.   Similar  cases  are mentioned by  Morgagni.   A
* Lancisi de Subitaneis Mortibus 
    INFLAMMATION OF THE ARACHNOID AND PIA MATER.  39

boy aged six, whose case is mentioned by Mr. Paisley,* was
seized with pain on  a particular spot on the  left side of the
head, followed by drowsiness, which proved fatal on the 12th
day, with the usual symptoms of hydrocephalus.  On the part
corresponding to the seat of the original pain,  there was a tu-
mour the size of a large hazel  nut, formed by a separation of
the laminae of the  dura mater, and the  deposition between
them of a  bloody serous  fluid.    There were several  si-
milar tumours, but of smaller size, along the course of the lon-
gitudinal sinus  on the left  side.  Besides the fluid,  the tu-
mours contained a  number of small white bodies like worms;
at the places where the tumours were formed, the dura  mater
adhered very fifmly to the  membranes beneath.  There was
much effusion under the arachnoid and in the ventricles.
                     SECTION IV.

   INFLAMMATION  OF THE ARACHNOID AND PIA MATER.

  Inflammation  of the  arachnoid, and  of the pia mater,
may be taken together.   It is very difficult to distinguish
them in practice, and as the affections are generally combin-
ed, it is probable that no important purpose can be answered
by attempts  to discriminate between their  symptoms.   The
disease terminates most commonly by a deposition of false
membrane betwixt the arachnoid and the pia mater.  When
this is found to spread uniformly over the surface of the con-
volutions, we may  suppose that it has been produced from the
arachnoid ; when it dips considerably between them, it is pro-
bable that the pia  mater has been affected; but, in point of
fact, it is  very  often  remarked  in these cases,  that the
pia mater  presents  a  most intense degree of vascularity,
even when there is no deposition  betwixt the convolutions,
while there is seldom any remarkable vascularity observed in
the arachnoid.  On this ground it has sometimes been doubt-
ed whether the arachnoid be really  the seat of inflammation.
   Some degree of this affection frequently  accompanies other
* Edinburgh Medieal Essays, vol. iii. 
40
MENINGITIS.
acute diseases of  the brain, but we very often find it entirely
uncombined, so that we  are  enabled to mark the symptoms
more immediately connected  with it.   In these,  however,
there does not appear to be any uniformity.  In some cases,
it comes on  with headach, vomiting,  fever and impatience of
light; but a frequent form in which the attack takes place, is
by a sudden and long continued paroxysm of convulsion.—
This is  in some cases  preceded by headach  and vomiting,
but in other  cases comes on without any warning.   The con-
vulsion is generally long and severe;  in some cases, it passes
immediately into  coma,  which  afterwards alternates only
with a repetition of the  convulsion, until in a few days the
case is fatal.  In other cases, there is recovery from the first
convulsion, and the patient appears to be doing well for some
time, perhaps for several days, but afterwards falls into coma,
either with  or without  a recurrence of the convulsion.   In
other cases again, the convulsion does not come on till  an ad-
vanced period of the disease.
  The following selection of cases will  illustrate the principal
phenomena  connected with this  important  affection, both in
children and in adults.   To prevent  circumlocution, I shall
employ the term Meningitis to express  the disease,  meaning
thereby the  inflammation of the  arachnoid, or pia mater, or
both, as distinct from inflammation of the dura mater.
  § I.—Simple meningitis in the most common form.

  Case VIII.—A boy aged  11,  had been for about a fort-
night remarkably listless and inactive,  and affected with  fre-
quent vomiting.   The vomiting had occurred every day, or
several times in the day;  his bowels were costive, but he did
not complain of any pain, and he was free from fever.  In the
evening of the 29th June  1816, he was seized with violent
convulsion, which recurred several times : in the  intervals he
had severe vomiting, and complained of headach ;  pulse 60.
The convulsion occurred frequently during the following night,
and in the inlervals he complained that he could not see.__
Towards morning, the convulsion ceased, and left him in a
state of the most profound coma.  The  coma continued till
mid-day of the 30th,  when it began to  abate after he had been
freely purged ; in the evening he was quite sensible, and com-
plained of headach, pulse 120. 
MENINGITIS.
11
  July 1st.—The ordinary remedies having been adopted, he
was  much relieved;  no  headach;  no  vomiting;  tongue
moist; pulse 120.
  2d.—Pulse 108 ;  no complaint; much disposed to sleep ;
pupils rather dilated.
  3d. Pulse 112; appearance much improved ; eye natural;
bowels open; tongue clean ;  no unusual drowsiness.
  4th.—Pulse 108 ; functions natural;  a good deal disposed
to sleep.
  5th.—Pulse 70; had an attack of vomiting, and complain-
ed much of his head ;  afterwards fell into a degree of stupor ;
was sensible when roused,  but was impatient of  being  dis-
turbed, and still complained of his  head; eyes natural; re-
peated vomiting;
  6th.—Perfect coma, with frequent convulsion ;  pulse from
120 to 160;  he frequently lay with the  one hand pressing his
forehead, and the other on the occiput.
  7th.—In profound coma the whole day; died  during the
night.
  Inspection.—On raising the dura mater,  the surface of the
brain  in  many places had a yellow appearance, which we
found to arise "from extensive deposition of adventitious mem-
brane under the arachnoid.  It was in general about the thick-
ness of a wafer; some portions of it were thicker, and in some
places masses of it of considerable extent lay between the
convolutions.  There was also  a good  deal between the he-
mispheres, which were partially glued  together by it.   The
principal seats  of this deposition were, the anterior part-of
both hemispheres, and the whole base of the brain, especially
the  depression betwixt the lobes;  and  it also covered nearly
the  whole surface of the cerebellum.  On the posterior part of
the  brain it was wanting, and  there the pia mater was evi-
dently inflamed.  The  surface of the brain, at  these places,
had also an inflamed appearance, but  this did  not penetrate
into its substance.   Some fluid was found in the base of the
cranium, after the brain was removed,  but there was  no  effu-
sion in the ventricles,  and the brain in other  respects was
healthy.

  Case IX.—A girl,  aged  9,  awoke  suddenly in the night
of 20th September, 1817,  screaming from violent headach,
and exclaiming that some person had given her  a  blow op. the
head.
                            6 
42
MENINGITIS.
  21st.—She complained of pain in the forehead, but she was
not in bed, and the pain was not severe.
  22d.—Little  change;  partly in  bed,  and complaining of
headach, but the complaint excited no alarm.
  23d.—Was seized with violent and  long continued con-
vulsion, which was immediately succeeded by profound coma.
  24th.—I saw her for the first  time; found her in  perfect
coma; the eyelids open, the eyes distorted upwards, the pulse
quite natural.   Continued in the same state on the 25th,  and
died on  the 26th.
  Inspection.—On removing the dura mater, the other mem-
branes appeared highly vascular as if inflamed, except where
this appearance was concealed  by a layer of yellow adventi-
tious membrane, spread out betwixt the arachnoid and the pia
mater.  This deposition was distributed in irregular patches,
over various parts of the surface of the  brain, but was most
abundant on the upper part of the right liemisphere.  It  was
in general of the thickness of a wafer, and in some places ex-
tended downwards betwixt the convolutions. There was  also
a considerable quantity of it on the surface of the cerebellum.
There was a good deal of gelatinous effusion about the optic
nerves,  and about an ounce of colourless fluid in the ventri-
cles.  The substance of the brain  was throughout'unusually
vascular.

   Case X.—A child aged 2 years, 21st May,  1826, was sud-
denly seized in the  morning with  severe and long continued
convulsion. It left her in a dull torpid state, in which she did
not seem to recognise the persons about her.   She had  lain
in this state for several hours, when the convulsion returned;
and, during the following night, it recurred a third time,  and
was very severe and of long continuance.  I saw her on the
morning of the 23d, and while I was sitting by her, she  was
again attacked with severe and long continued convulsion,
which affected  every part of the body,  the face and the eyes
in particular being frightfully distorted. The countenance  was
pale and  expressive of exhaustion, the pulse frequent;  her
bowels had been freely opened by medicine, previously pre-
scribed by Dr.  Beilby, and the motions were dark and  un-
healthy.   Farther purging was employed, with topical bleed-
ing, cold applications to the head, and blistering.   After  this
attack, she continued free  from convulsion till the afternoon
of the 23d ; in  the  interval she had remained in a partially 
MENINGITIS.
43
comatose state, with frequent starting, pulse frequent, but fee-
ble, pupil rather dilated ;  she took some food.   In the after-
noon of the 23d, the convulsion returned with great severity ;
and on  the  24th,  there  was a constant  succession  of pa-
roxysms during the whole day, with sinking of the vital pow-
ers; and she died early in the evening.
  Inspection.—On  removing the dura mater, the surface of the
brain appeared in many places covered by a deposition of ad-
ventitious membrane, betwixt the arachnoid and pia mater. It
was chiefly found above the openings  between  the convolu-
tions, and in some  places appeared to dip a little way between
them.  The arachnoid membrane when detached appeared to be
healthy, but the pia mater was throughout in the highest state
of vascularity, especially between the convolutions ; and when
the brain was cut vertically, the spaces between the convolu-
tions were most  strikingly marked by a bright  line of vivid
redness, produced  by the inflamed  membrane.   There was
no effusion  in the  ventricles, and no other  morbid appear-
ance.
§  II.—Meningitis  of unusually  great  extent, with
            «    VERY OBSCURE SYMPTOMS.

   Case XI.—A child aged between  3 and 4, had scarlatina
mildly in the middle  of June 1824, having been confined only
four or five days.  He had been down stairs for several days,
and once or twice out of doors ;  when, on the evening of the
23d, he became feverish, and complained of his bowels.   Af-
ter the operation of some laxative medicine he was much re-
lieved on the 24th ; his pulse, however,  continued frequent.
On the 25th,  he again complained of his bowels,  and  was
feverish; but in the  evening he was  again relieved, and no
symptom was  remarked by Mr. White, except that his pulse
continued slightly frequent, and at one time he complained of
uneasiness in his eyes.   In the night  he was restless, but  still
complained only of  his belly; his bowels had  been freely
moved, and the motions were natural. On the 26th, he  had
frequent  vomiting, and in the evening  became  oppressed ;
pulse 120.   I  saw him for the first time at night.   He  was
then in a state of oppression, evidently verging towards coma ;
could be roused, but  without taking much  notice of objects ;
pulse 120; countenance and eye  natural.  Topical bleeding, 
44
MENINGITIS.
purgatives, cold applications, &c, were employed.  In the
night there was  frequent vomiting,  every medicine  being
brought up, and the bowels were  not moved.  On the 27th,
the coma was increased, and there were through the day fre-
quent convulsive affections of the  face and arms;  pulse 120,
and weak; pupil dilated, and the  eye insensible; died early
in the morning  of the 28th.
   Inspection.—On removing the dura mater,  the whole  sur-
face of the brain was found to be covered by a continued stra-
tum of yellow adventitious membrane, deposited betwixt the
arachnoid and pia mater.  It was thickest above the openings
between the convolutions ; in many places it was  traced dip-
ping between them to the depth of half an inch ; and in some
places, on the right side of the brain, it followed the course of
the pia mater through the whole depth of the convolutions.—
The deposition  was general over the whole brain,  and on the
upper and  anterior parts of the cerebellum ; and there was a
good deal of it  about  the  optic nerves.   The pia mater and
the  arachnoid  adhered  everywhere very firmly together by
means of it; when they were  separated, the arachnoid  pre-
sented  no  unusual appearance,  but the pia mater showed
throughout the  highest degree of  vascularity ; the deposition
was entirely confined to the  space between  the membranes,
for no vestige of it could be traced either on the outer surface of
the arachnoid or  the inner surface of the pia mater.   There
was no  serous  effusion, and the  brain and the  cerebellum
were perfectly healthy ;  the bowels were in many places irre-
gularly distended with flatus.
§ III.--MENIGITIS OF  VERY SMALL EXTENT, WITH  SEVERE
                       SYMPTOMS.

  Case XII.—A child aged 6 years, 24th January 1822, had
severe headach and some vomiting, followed by extreme ob-
stinacy of the  bowels,  which resisted  the most active medi-
cines for six days. During this time she complained constant-
ly of headach,  and the vomiting recurred from time  to time,
but was not severe, the pulse varying from 90 to 100.  General
and topical bleeding, with the most active purgatives and in-
jections had been employed with  every possible assiduity by
Dr. Hay.   On the 6th day the bowels began to yield,  and
about the 10th, there was a remarkable improvement of all the 
MENINGITIS.                    45
symptoms, pulse from 80 to 90, and the headach nearly gone.
This favourable  state continued for  two days ; the headach
then returned, and on the following day, the 13th of the dis-
ease, considerable hesitation  of speech was  observed, with
slight delirium occurring at intervals.   On the 14th, she was
in these respects better, but still complained of headach,
which was referred to the forehead ; pupils dilated ; pulse fre-
quent.   On the 15th, slight convulsion was remarked several
times through the day, and the pain of the forehead was still
complained of.  On the 16th, she was in the morning distinct
and intelligent, but still complained of headach;  pulse 120.
Through the day, the pidse varied from 90 to 140, the pupil
was dilated, and the vision imperfect, but she continued quite
intelligent  till eight  o'clock in the evening ;  she was then
seized with severe convulsion, which continued without inter-
mission for two hours, when she died.   This very important
case was most minutely attended to through its whole course,
and all the usual remedies were employed in the most active
manner.
  Inspection-There was no effusion in the ventricles, and every
part of the brain presented  the most healthy appearance, ex-
cept a small part on the lower surface of the anterior lobe  of
the right hemisphere, where it lies over the orbit.   There was,
at this place, a distinct deposition of adventitious membrane
of an extent scarcely larger than a shilling.  Immediately con-
nected with it, the substance of the brain was sensibly harden-
ed, to an extent corresponding to the size of a large nut.   No
other disease could be discovered in any organ.


         §  IV.—Meningitis of  the  base.

  Case  XIII.—A young  lady aged  14, was affected with
symptoms resembling those of mild continued fever, which ex-
cited no alarm till about the end of the second week, when
the headach became more severe, with  some oppression and
transient incoherence.  I saw her, for the first time, in the be-
ginning of  the third  week; there was  then a  degree of op-
pression, tending to coma ; the pupil was dilated ; pulse from
110 to 120; the tongue foul.   For some days the symptoms
varied considerably;  sometimes showing a degree of coma,
but generally rather exhibiting  the characters of typhus.   The
eyes, however, appeared to be insensible to the light, and once 
46
MENINGITIS.
or twice a degree of squinting was observed, but it went off;
sometimes she answered  questions distinctly, and  sometimes
not; the pulse varied from 110 to  130.  On the  day before
her death, she was much more sensible, and upon the whole
considerably relieved; but next day she was more comatose,
and her strength was sinking; and  she died at night, about
three weeks from the commencement of the disease.   Several
of the family had died of hydrocephalus.
   Inspection.—The substance of the brain was healthy; the
ventricles contained about two ounces of fluid; there was a
considerable deposition of adventitious membrane on  the sur-
face of the Pons  Varolii, which extended forward along the
base of the brain; there was a good deal of it in a more recent
state about the  optic nerves, and it was traced upwards  to-
wards the third  ventricle.
 § V.—Meningitis  with suppuration on the surface.

  Case XIV.—A  child  aged 8 months, died 13th  March,
1818, of an illness which had continued more than three weeks.
It began with fever, restlessness, and quick breathing;  after-
wards there were frequent  convulsive affections, with  much
oppression,  and  at  last severe convulsions,  squinting, and
coma.  At an early period of the complaint, there was observ-
ed a remarkable prominence of the anterior fontanelle ; in the
second week, this  increased considerably; and  in the third
week, it was elevated into  a distinct circumscribed  tumour,
which was soft and  fluctuating,—and pressure upon it  occa-
sioned convulsion.   It was  opened by a small puncture, and
discharged at first some  purulent matter,  afterwards bloody
serum.  No change took place in the symptoms, and the child
died four days after.
  Inspection.—The  opening which had been made  through
the fontanelle, was found to lead to a deposition of thick floc-
culent matter mixed with pus, betwixt the dura mater and the
arachnoid and covering the surface  of the brain to a conside-
rable extent.   There was a similar deposition between  the
arachnoid, and  the  pia mater, which extended between  the
convolutions, and there was a good  deal of it about the optic
nerves and under the medulla oblongata; there was consider-
able effusion in the ventricles. 
MENINGITIS.
47
§ VI.—Meningitis with suppuration within the  ven-
                         tricles.

   Case XV.—A child  aged 5 months, previously in perfect
health, was seized with  convulsion on the evening of the ^ 1st
November,18l7.   The attack, which was not of long duration,
was ascribed to dentition; the  gums were  divided  over se-
veral teeth that appeared  to be producing irritation, and the
other remedies were employed that are usual in such affections.
He continued well through the night; on the 22d, he was op-
pressed, with quick breathing, and in the afternoon, without
any return of convulsion,  he fell into a state of coma.   This
continued several hours, and then subsided, after topical bleed-
ing, active purging, and the  use of cold applications to the
bead.   On the  23d, he  was much relieved; eye natural;  he
took notice of objects, and was disposed to play, and no com-
plaint was remarked, except occasional starting.   On the 24th,
he continued through the day in the same favourable  state ;
but late at night he was seized with convulsion, which con-
tinued without intermission through the night, and he died
early in the morning.
  Inspection.—There was an extensive deposition of adventi-
tious membrane betwixt the arachnoid and pia  mater; it co-
vered a great part of the upper surface of the brain, and there
was a considerable quantity of it on the inferior surface of the
anterior lobes, between the hemispheres, and on the cerebellum.
In the lateral ventricles, there was about an ounce of purulent
matter, and the substance  of the brain surrounding the ventri-
cles was very soft; there was no serous effusion.  There was
much gelatinous deposition about the optic nerves, under the
base of the brain, and under the cerebellum.   Below the me-
dulla  oblongata, there  was a similar deposition mixed  with
some purulent matter.

  There seems  reason to believe that the arachnoid, lining the
ventricles, is more frequently the seat of inflammation  than
has been commonly supposed, in those cases which terminate
either by simple effusion in the ventricles, or  by the deposition
there of flocculent or puriform fluid.   M. Gendrin has describ-
ed several cases of this description,  in which the lining mem-
brane of the ventricles was much thickened;  and one in which 
48
MENINGITIS.
the posterior part of both ventricles was lined with false mem-
brane, and their cavities filled with a milky fluid.   The  case
was that of a girl of 13, weakened by a succession of abscesses ;
and it was  complicated  with  meningitis in  the  ordinary
form.   The symptoms were pain in the left side of the head,
—vomiting,—fever,—delirium,—palsy of the left arm, and
contraction of the right,—and she died in a state of coma, in
about five days.   Dr. Bright has also described several cases
in which the ventricles contained pus,—but they were not dis-
tinguished by any symptoms from the other inflammatory af-
fections.
        § VII.—Meningitis of the cerebellum.

  Case XVI.—A lady aged 45, liable to suppuration of the
left ear, complained of pain in that ear, May 11,  1821.   On
the two following days, the  pain extended  through the head
with fever; and on the 14th, she complained of general head-
ach, and a violent  and painful feeling of throbbing in the back
part of the head.   She was deaf, and inclined to  drowsiness,
but quite sensible ; pulse 120 and very strong ; large  blood-
letting and the  other usual remedies were actively employed
on this and the following days by Dr. Thatcher  and the late
Mr. Bryce.  I saw her on the  16th ; there  was then  a good
deal of coma, but she was sensible when roused;  the eye na-
tural, the  tongue clean, pulse 130;  she  still complained  of
headach when she was closely questioned, but  did not  make
any complaint except when she was  much roused.  The pulse
being now considerably reduced in strength, topical bleeding
only was employed.   In the evening  she was  more easily
roused,  and said she felt better; in the night,  she became
again extremely restless and incoherent, and died early in the
morning.   There had been  a slight discharge of  matter from
the left early in the disease.
  Inspection.—There was slight effusion in the lateral  ventri-
cles ; the brain in  other respects  was healthy.   On the outer
surface  of the cerebellum there was  a uniform deposition  of
thick puriform matter; it was most abundant on the left side.
The pia mater of the cerebellum was highly vascular, the du-
ra mater was healthy; there was  some purulent matter about
the pituitary gland, and in the cavity of the ear, but there was 
MENINGITIS.
49
no appearance of disease of the bones connected with the ear,
or of the dura mater covering them.

   Uncombined meningitis of the cerebellum seems  to be an
uncommon affection.   An  interesting example of it is men-
tioned by Dr.  Dunglison in the London  Medical  Repository.
A boy aged 5, pale and delicate, after being slightly indispos-
ed for  four or five days, was seized in the night of 9th  Au-
gust with violent convulsion.  On the 10th, there was fever
with delirium ; a vacant look of the eye, and an evident  im-
perfection of vision, which  appeared by his attempting to lay
hold of objects that were presented to him, and missing them.
There was dilated  pupil, and slight  strabismus.   11th, 12th,
13th, and 14th, Symptoms  gradually increasing; 15th, coma ;
constant motion of the right arm and leg;  the left appeared to
be paralysed.   In  the night was seized  with violent convul-
sion, which continued till  his death; this took place on the
morning of the 16th.   The brain was healthy.  There was a
remarkable vascularity on the tuber annulare, forming a thick
web of vessels.  It was connected with the arachnoid coat of
the right side of the cerebellum,  which was  thickened  with
some deposition of coagulable lymph.  About 4 ounces of fluid
was found in the base of the skull, but not above  a teaspoon-
ful in the ventricles.

   These cases will serve to illustrate the remarkable diversity
of symptoms  which accompany this affection.   I have select-
ed them  as calculated to exhibit the pure  meningitis  uncon-
nected with any other considerable disease of the brain.   The
convulsive affections of children, which  are apt to be  indis-
criminately ascribed to dentition, are, I think, frequently con-
nected with this disease.   In such cases, instead of the depo-
sition of adventitious membrane, we frequently observe a thin
but extensive coating of puriform  fluid on the surface of the
pia mater.


  § VIII.—A  DANGEROUS  MODIFICATION  OF THE DISEASE
      WHICH  SHOWS  ONLY INCREASED VASCULARITY.

   Another important modification of the disease occurs in an
insidious and highly dangerous  affection, which  I think has
been little attended to by writers on the diseases of the brain.
                            7 
50
MENINGITIS.
It is apt to be mistaken for mania, or, in females, for a modi-
fication of hysteria; and in this manner the dangerous nature
of it has  sometimes been overlooked, until it proved rapidly
and  unexpectedly fatal.  It sometimes commences  with  de-
pression  of spirits, which  after a short time  passes off very
suddenly, and is at once  succeeded by an unusual degree of
cheerfulness, rapidly followed  by maniacal  excitement.   In
other cases, these preliminary stages  are less remarkable; the
affection, when it first excites attention, being in its more con-
firmed  form.  This is in general distinguished by remarkable
quickness of manner, rapid, incessant talking, and rambling
from one subject to another, with obstinate watchfulness, and
a small frequent pulse.   Sometimes there is  hallucination, or
conception of persons or things which are not present, but in
others  this  is entirely wanting.   The progress  of the affection
is generally rapid;  in some cases, it  passes into convulsion
and coma; but in general it is fatal by a  sudden sinking of
the vital powers, supervening upon the high excitement, with-
out coma.   The principal morbid appearance is a highly vas-
cular state  of the pia mater, sometimes with  very slight effu-
sion betwixt it  and the arachnoid.   The disease is one of ex-
treme  danger, and  does not in general admit of very  active
treatment.   General bleeding is not borne well, and the treat-
ment must in general be confined to topical bleeding with pur-
gatives, antimonials, and the powerful application of cold to
the head.  The affection is most common in females of a de-
licate, irritable  habit, but also  occurs in  males, especially in
those who have been addicted to intemperance.  I have how-
ever seen it in  one case, in a gentleman between 40 and 50,
of stout make and very temperate habits.   The cause of death
is obscure; it seems in general to  be a sudden sinking of the
vital powers, supervening upon the  high excitement without
any of the actual results of inflammation.

   Case XVII.—A lady aged  23, had suffered much distress
from the death of a sister, and hadT>een affected, in consequence,
with impaired appetite and want of  sleep; this had gone on
for about two months,  when  on the  4th of August  1825, she
sent for Dr. Kellie, and said she wished to consult him about
her stomach.  He  found her rambling from one subject to an-
other with extreme rapidity and considerable incoherence • and
 on the 5th, she was in a state of the highest excitement with
incessant  talking,  alternating  with  screaming and singing; 
MENINGITIS.
51
pulse from 80 to 90.   In the evening she became suddenly calm
and quite sensible after an opiate ; continued so for an hour or
more, then fell  asleep, and after sleeping two hours, awoke
in the same state of excitement as before.   The  same symp-
toms continued on the 6th; the pulse in the morning was lit-
tle affected, but after this time it became small and very rapid.
On the 7th, after a night of great and constant excitement, she
had another lucid interval, but her pulse  was now 150.  The
excitement soon returned, and continued till four in the after-
noon, when she fell  asleep.   She  awoke about  eight, calm
and collected, but with an evident tendency to coma; pulse
150, and small.   She now took food and wine, and  passed
the night partly in a  state of similar  excitement, and  partly
comatose;  and died  about mid-day of  the 8th, having  con-
tinued to talk incoherently, but knowing those about her,  and
in general understanding what was said  to her.
   Inspection.—The only  morbid appearance that could be  dis-
covered was a highly  vascular state of the pia mater, with nu-
merous red points in the  substance of the brain.

   Case  XVJII.—A  gentleman, aged 44, of a stout make,
and very temperate habits, became suddenly affected, without
any known cause, with extreme depression of  spirits, accom-
panied by a good deal of talking and want of sleep.  After
this condition had continued for two days, it went off sudden-
ly, and he  recovered  excellent  spirits and  talked cheerfully.
This, however, was soon succeeded by a state of excitement,
with rapid incoherent talking, and obstinate watchfulness;
and the pulse rose rapidly to 160.  This state continued with-
out abatement for about four days, when he suddenly sunk in-
to a state of collapse and died.
   Inspection.—The only  morbid appearance was a highly vas-
cular state  of the pia mater and arachnoid, with slight serous
effusions betwixt them.

   This obscure and dangerous affection is sometimes met with
in connexion with other diseases, especially acute rheumatism
and other inflammatory affections, and sometimes attacks fe-
males in the puerperal state.  It is unnecessary to give a length-
ened detail of cases, which do not tend to throw any addition-
al light upon the nature of it.  A young lady, whom I  saw
with Mr. Turner, had acute rheumatism  in a very slight form
for three days, her pulse from 90 to 96 ; on the  fourth day, 
52
MENINGITIS.
the pains ceased, and in the evening, she began to talk a great
deal  and rather incoherently, but made no complaint.  On the
fifth  day, she was more  tranquil, but at night the incoherent
talking returned.   I then saw her for the first time; she was
talking a great deal wildly and incoherently, but, when her at-
tention was  arrested, she answered  questions distinctly;  the
pulse was 120; the tongue rather loaded, but moist;  and  she
did not complain of any uneasiness.   On the sixth day, these
symptoms continued;  in the evening she became  comatose,
and died in the night.  Bloodletting was employed, and  va-
rious other remedies, without benefit.  A soldier, aged 34, for
whose case I am indebted to the late Dr. Hennen, had  acute
rheumatism in a severe form, combined with pneumonic symp-
toms.  He was relieved by bloodletting, but his pulse conti-
nued frequent, and be had some palpitation of the heart,  but
not severe.   On the  fifteenth  day of the disease, he became
suddenly comatose, and died  in a few hours.   In both  these
cases the appearances on  dissection were altogether  unsatis-
factory.

   The above remarks on this highly dangerous and  interest-
ing affection, I leave as they stood in the first edition of  this
work.   Since that time I have seen several examples  of it,
and  have  been induced to adopt a different mode of treatment,
which seems to promise some interesting results.   Without
at present venturing  upon any  general conclusions, I shall
merely submit the  following case.

   Case XIX.—A lady aged  about 38, was recovering from
her eleventh accouchment, when, at the end of a fortnight, she
became affected with a deep-seated  hard swelling in the right
side of the  pelvis, which was tender to the touch, and  was
accompanied by a considerable degree of fever.  After, repeated
topical bleeding and other remedies, the febrile state subsided',
the  swelling lost its tenderness,  and seemed  to be gradually
diminishing in size; but its progress was very slow, and, af-
ter three or four weeks, she was still confined to bed, and suf-
fering a good deal of uneasiness;  her pulse  was now  calm,
but  she was considerably reduced in strength.   At this time
 she  became, one  day, alarmed  and agitated  by some family
 occurrence, and immediately began to talk wildly and inco-
 herently, and after a  restless  night  was found next day in a
 state of the highest excitement, talking incessantly, screaming 
MENINGITIS.
53
and struggling, with a wild expression of countenance, and a
small rapid pulse.   She was treated by topical bleeding, lax-
atives, cold applications to the head, &c, but with little or no
benefit; and on visiting her on the following day, I found her
sitting up  in bed, with a look of extreme wildness, both  her
hands in constant motion, talking incessantly and wildly; and
I learnt that she had not ceased talking for one instant for the
last twelve hours.   Her pulse was  now rapid  and feeble, and
her countenance  expressive of exhaustion.   In consultation
with a highly intelligent friend who had charge  of the case, I
mentioned my experience of the fatal nature of  the affection,
and proposed  to  make trial of treatment by stimulants.  A
glass of wine was accordingly given, with evident abatement
of the  symptoms;  and it was ordered to be repeated  every
hour.   At the end of the fourth hour, she was  perfectly com-
posed and rational, her pulse about 90 and of good strength ;
and from  this time there was no return of the symptoms.  The
tumour in the  right side increased in  size,  suppurated, was
opened and healed favourably.  From this time she continued
in perfect health, and  has since passed through another ac-
couchment in the most favourable  manner.
   This case I have given as another example of this interest-
ing affection.   I have employed the same mode of treatment,
with similar benefit in several other cases, both of males and
females.  The chief difficulty is in deciding upon the parti-
cular cases to which the stimulating treatment  is applicable.
They  appear to be  those in which  the excitement  is accom-
panied by a  small and rapid pulse,  and an  expression  of
paleness and exhaustion.   When these characters are present,
however violent the excitement may be, I have not been de-
terred from the practice, and in a considerable  number of in-
 stances I have found much reason to be satisfied with  it.  I
 have tried it, but without  the same benefit,  in some  of the
 common  cases of insanity, accompanied by paleness and bo-
 dily weakness, but with a natural pulse.    When  there  is
 frequent and strong pulse, with flushing and other marks  of
 increased vascular  action, it would of course be injurious.

   •An affection analogous to this occurs in habitual drunkards.
 The symptoms, in such cases, may either follow a particular
 instance  of excess, or  they  may  appear  in  connexion with
 some incidental febrile disturbance produced by cold, or any
 other ordinary cause;  and sometimes they follow slight inju- 
54
MENINGITIS.
ries.   There is generally great irritability  and restlessness,
with sleeplessness or disturbed sleep, sometimes delirium, al-
most amounting to mania: and generally a small rapid pulse.
This state of excitement may either be  followed by sudden
sinking and death,—£r it may pass into coma and  be fatal
more gradually.  In other cases there is not  the  high deli-
rium, but a febrile state of restlessness, passing into coma.
On dissection there is often little seen, except increased vas-
cularity of the membranes, and some serous effusion under the
arachnoid, and sometimes a little in the ventricles.   In other
cases a deposition of puriform matter is found under the arach-
noid.

  An affection occurs in children  which presents the same
obscurity in  the morbid appearances as in  these remarkable
cases, though with different  symptoms.  The child is gene-
rally attacked with a succession of convulsions, and is cut off
within  various  periods, from  one to three or four days.  It is
apt to occur in connexion with other diseases, especially hoop-
ing cough.

  Case XX.—A  child aged two  and a half years, affected
with hooping cough in a very mild form, was attacked, in  the
end of May  1822, with a convulsive twisting of the hands, to
which she had been formerly liable  at an early period of life;
this excited no alarm, till the 4th of June, when she was seized
with general convulsion, accompanied with fever, headach,
and an obstinate state of the  bowels.   All the usual remedies
were employed with activity, but  the convulsions  continued
to recur several times in the day, and she died on the 8th.
The cough  had gone on, but in a mild and favourable form.
  Inspection.—There was slight increase of vascularity of the
pia mater, with numerous red  points throughout the  medullary
substance of the brain.   No other disease could be discovered
on the  most  careful examination, and all the other organs were
healthy.

  Case XXI.—A child  aged 5, affected with hooping cough,
on  the 5th June 1822, was  seized with headach and  fever;
had afterwards irregular motion of the eyes with  occasional
squinting, then violent convulsions, which recurred frequently
and alternated with coma; and he  died in three days.   After
death,  nothing  could be discovered, on the most careful ex- 
MENINGITIS.                     55
animation, except  increased vascularity of the pia mater in
several places.

  Case XXII.—A child, aged three years  and a half, had
been for several days slightly feverish,^ith some cough, but
the  complaint was considered as trifliirg, and she was sitting
at table on the evening of the third of  April, when she sud-
denly lost her speech, and soon afterwards was seized with gene-
ral convulsion.  She continued in a state of constant and violent
convulsion, with complete insensibility, for several hours; in
the  course of the night the convulsion abated—she 'recovered
the  power of swallowing, which had been lost, and took pur-
gative medicine, which operated powerfully.   On the 4th, the
convulsion returned with  great violence; she had a constant
succession of paroxysms during the day, and in the intervals
was in a state of coma.   She died early on  the 5th.   On in-
spection, no  disease could be discovered, except increased
vascularity of the membranes of the brain, and turgidity of the
veins upon the  surface.

  I have notes  of  several cases resembling this in the symp-
toms, and presenting the same obscurity in the morbid appear-
ances.   They occurred in strong healthy children from two to
four years of age, and were fatal generally about the third day,
and under various modes of treatment.

  It is unnecessary to multiply examples of  this kind, which
only serve to shew us  the imperfection of our knowledge on
the  pathology of the brain.   In the  following singular  case,
the  affection here  referred to  seemed to have taken  place in
the  course of another  disease of the" brain, and to have been
the  immediate cause of death, before the primary affection had
been so far advanced  as to have the nature of it distinctly
characterized.

  Case XXIII.—A child, aged 4 years, of a family who had
lost many children from various  forms of disease, had been
affected for about ten or twelve days, with a feverish disorder,
which had not shown any alarming symptom.  The complaint
appeared to be  subsiding, and, on the day on which he died,
he had been considered as convalescent by two medical men
of the first eminence.   In the afternoon of that day, his mother
observed that his  eyes became  suddenly fixed  and vacant. 
56
MENINGITIS.
Soon after, he was seized with most violent general convul-
sion,  which continued, without  intermission,  for  about five
hours, when he died.
  Inspection.—There was considerable effusion in  the ventri-
cles, and a good deal of ramollissement of the septum and for-
nix.   The only other morbid appearance was a most extensive
and high degree of vascularity of the pia mater.

  Inflammation  of the  arachnoid and pia mater  appears  to
occur in a more chronic  form, in which it may go  on for a
considerable time, spreading  from one  part of the  brain  to
another, and producing a succession of symptoms, as the parts
become successively affected.   A lady,  mentioned by Mr.
Howship,* had severe headach, impatience of light, and para-
lysis of the left arm and leg.  After a  short time the paralysis
was removed, but the arm continued so painful as to be nearly
useless.   The  pain of the head continued,  and, after two
months, extended downwards upon the neck and back.  She
had then retention of urine, severe throbbing pain of the back
and loins, convulsive contraction of the shoulders, and pain
shooting through from  the back to the breast.   She  had at
last intense pain in the head,  neck, back, and whole body,  so
as to be unable to move a single limb, and died gradually ex-
hausted, four months after the commencement of the disease.
On inspection, serous effusion was found under the arachnoid,
with extensive  deposition of  coagulable lymph on the upper,
lateral, and inferior parts of the brain, and the anterior part
of the medulla oblongata: and the same disease was found to
have extended along the membranes of the spinal cord.
  Chronic disease of the pia mater and arachnoid is met with
in various forms; in some cases, consisting of thickening of
the membranes themselves; in others, with old depositions of
false membrane;  and in some, the affection is complicated with
tubercular disease of the pia mater.
  A gentleman mentioned by Dr. Powel,f after having been
affected for a fortnight with  slight headach, became incohe-
rent, with a considerable degree  of stupor, dilated pupils, and
indistinct articulation:  and he died in another fortnight.  The
pupil of the right eye was more dilated than that  of the left,
and, a short time before his death, the nght side became pa-
ralytic.   On inspection, effusion was  found in the ventricles
* Howship's Practical Observations in Surgery and Morbid Anatomy.
t Transactions of the College of Physicians of London, vol v. 
MENINGITIS.
57
 and deposition of coagulable  lymph about  the pons Varolii.
 At the anterior part of the middle lobe of the brain—he does
 not say in which hemisphere—the pia mater was much thick-
 ened, and its inner surface was  studded with small tubercles,
 like large pin heads.   Similar tubercles were observed in other
 parts of it, especially where it lies betwixt  the convolutions.
 This tubercular disease of the  pia mater does not appear to be
 a common affection, but a very remarkable case of it is men-
 tioned by Dr. Clark.*  A man  aged 35, addicted to intoxi-
 cation, was seized with fever and cough, followed by vomit-
 ing, bloody stools, drowsiness,  and muttering; but he  was
 not entirely confined for the first fourteen days ; after this he
 became worse, with severe headach, much cough, subsultus,
 drowsiness and deafness, pulse 116, tongue  dry and brown.
 He had  then delirium, impatience of  light, and a degree cf
 coma; but he was relieved by bleeding, and the pulse fell to
 96.   He  died'suddenly on  the 24th day, having'been out of
 bed and  eating heartily the day before.   On inspection, the
 dura mater was found perforated by small orifices, which trans-
 mitted flesh-coloured tubercles.  These appeared to arise from
 the pia mater, and had no connexion with the brain ;  some of
 them were of the  size of small peas, and  were  received  into
 depressions of the cranium, some  of which were one-sixth of
 an inch in depth.   The arachnoid was thickened, and in some
 places adhered to the pia  mater;  in other places, coagulable
 lymph was deposited betwixt them; there was some fluid in
 the ventricles.
  Thickening of the membranes, and adhesions to each other,
 are met with  in many cases, probably the result of inflamma-
 tory action of old  date.  Such cases are mentioned by Wep-
 fer, Willis, and others, in some of which the patients had been
 long liable to headach.   Similar appearances have been  ob-
 served in old maniacal cases.   A  man is mentioned by  Dr.
 Powel, who had  been two years  insane,  and died  fatuous;
 he had been liable at uncertain intervals, to convulsive attacks,
 in which the left side of the body suffered more than the right.
 An adventitious membrane of the thickness of three sheets of
 writing paper, was found covering the whole right hemisphere
 of the brain;  it became thinner on the lower parts of it,  and
was gradually lost at the base ; the left hemisphere was entire-
ly healthy.

             * Edinburgh Medical Journal, vol. v. p. 261.
                            8 
58        INFLAMMATION OF THE HEMISPHERES.
                      SECTION V.

 INFLAMMATION OF THE SUBSTANCE OF THE HEMISPHERES.

  In the symptoms accompanying inflammation of the sub-
stance of the brain, there are considerable varieties, depending
probably on the extent of the disease, and the particular part
of the brain which is the seat of it.   We find  in some cases,
headach, followed by  high  delirium, and this by  coma; in
others, a sudden attack of convulsion.   A frequent and very
important form of the disease  is characterized by headach,
followed by convulsion of one  or  more limbs, the affected
limbs afterwards  becoming paralytic.  Other cases again  as-
sume a close resemblance to the ordinary attack of hemiplegia,
so as scarcely to be distinguished from it;  and a very interest-
ing feature of the affection in these cases is, that the disease
in the brain may not have extended beyond the state of simple
inflammation, though the symptoms have passed through their
usual course, and have terminated in fatal coma.
  In the progress of the disease, considerable modifications
occur, arising from the various ways in which the inflamma-
tion terminates; in these we are chiefly to attend to the fol-
lowing varieties.
  I. It may be fatal in the inflammatory stage;—A certain de-
fined portion of the cerebral substance presenting the appear-
ance of deep redness without any change of structure.
  II. The simple ramollissement; which consists in a part of
the brain being broken down into a soft pulpy mass, retaining
the natural colour of the part, without any appearance of sup-
puration, and without fetor.   This condition we often find as
the only morbid appearance, but we frequently find it combined
with the former, one portion of the diseased mass presenting
the deep red colour, while another is in a state  of ramollisse-
ment.
  III.  The preceding appearance mixed with a proportion of
purulent matter.
  IV.  The undefined suppuration.    This might  perhaps  be
considered as a modification of the former, but with  the puru-
lent matter predominating  in quantity.   It, presents a large,
ragged, undefined cavity, filled partly with fetid purulent mat- 
FATAL IN THE INFLAMMATORY STATE.         59
ter, and partly with broken down cerebral substance, the sur-
rounding substance being soft and disorganized.
   V.  The defined or encysted abscess.   This consists of a well-
defined, regular cavity, filled with purulent  matter, generally
lined  by a soft cyst, and  surrounded by cerebial matter in a
healthy state.
   VI.  Ulceration of the surface of the brain.
   Important  modifications also  occur in connection  with the
character of the disease in regard to activity.   In particular,
there appear to be some very interesting phenomena, connect-
ed with a chronic form  of it, in which it may continue for a
considerable time without advancing to a fatal termination, or
in which the symptoms may remit so as to assume a peri-
odical  character.   These  various  modifications will  be illus-
trated by the  following selection of cases.


  § I.--THE  INFLAMMATION OF THE  CEREBRAL SUBSTANCE
           FATAL IN THE INFLAMMATORY STAGE.

   Case XXIV.—A woman aged 26, had laboured under bad
health in a variety of forms for 18 months before her death.
Her complaints began with severe headach, and frequent at-
tacks of convulsion.  After some time, these symptoms sub-
sided, and  she was  seized with cough, hemoptysis, quick and
laborious breathing, and scarcity of  urine.  The affection of
her breathing came  on in paroxysms, during which her respi-
ration was  80 or 90 in a minute, and sometimes continued in
this state for several days together, her pulse  being constant-
ly frequent.  After  she had suffered  for many months from
these complaints, they subsided entirely without any  obvious
cause.   She then became  affected with violent  paroxysms of
pain in the abdomen, dysuria, and vomiting.  The pain was
principally in the right side of the abdomen, which was swell-
ed, tense,  and  painful upon  pressure ; the  paroxysms  were
succeeded  by copious discharges  of puriform fluid from the
vagina ; and  there was a temporary alleviation of the  pain af-
ter every discharge  of  this fluid.   The last time I saw her,
which was a few weeks before her death, there was a general
swelling and  hardness  occupying the whole right side of the
abdomen, extremely tender to the  touch,  and conveying the
impression of extensive organic disease.  I did not see her
in the fatal attack, which was in the head ; it began with se- 
60        INFLAMMATION OF THE HEMISPHERES.
vere headach, impatience of light, and fever ;  these were suc-
ceeded by convulsion, and this  by coma;  and she died co-
matose about a week after the commencement of this attack.
   Inspection.—I was present at the examination of the body,
and found the surface of the brain in many places of a dark
red colour.  This appearance extended in same places to the
depth of an  inch  into the substance of the  brain, and was
principally observed in  the upper  and anterior parts of both
hemispheres, and on the posterior part of the left hemisphere.
The parts so affected were rather softer than the other parts of
the brain, and appeared to be more vascular, for drops of blood
exuded  from them when they were cut.   The  internal parts
of the brain were healthy, and there was no  serous effusion.
The longitudinal sinus near its posterior part was thickened
in its coats, so as considerably to diminish its  area. The hard-
ness of the abdomen, which was so remarkable a short time
before death, had  disappeared ;  and not a vestige of disease
could be detected in any of the viscera of the thorax, abdo-
men, or pelvis.

   Ca se  XXV.—A lady aged 40, had been for some time af-
fected with irregularity of the menstrual discharge,  such as
she supposed to be a prelude to its cessation.   But, for some
days previous to the attack to be now described, the discharge
had been present, and very copious, so that she felt weaken-
ed by it. This continued on the 26th October, 1825;  and, in
the evening  of that day, on rising suddenly  from her chair,
she fell down on the floor in a state of syncope, but soon re-
covered, and felt no farther inconvenience.   She passed ra-
ther a restless night, but without any particular symptom, ex-
cept that early in the morning she complained of slight unea-
siness in the back of her head.  Soon after this, she was sit-
ting up in bed taking her breakfast with appetite, when, with-
out any warning, she fell backward in a state  of the most vio-
lent general  convulsion, with every character of perfect epi-
lepsy.   The convulsion soon subsided, leaving her in a state
of coma ;  after a short  time, the fit  returned,  and, from 9 in
the morning to 4  in the  afternoon, she had about fifteen at-
tacks of most severe and general convulsion, without ever re-
covering her senses in any degree between the attacks.  Dur-
ing all this time, she was incapable  of swallowing;  the eye
was insensible, and the pupil rather contracted;  the face pale
and sallow.   The pulse varied exceedingly, being sometimes 
FATAL IN THE INFLAMMATORY STATE.
61
of good strength, and little increased in frequency ;  at other
times, especially after the convulsion, it was frequent and fee-
ble.   General and  topical bloodletting were  employed with
cold applications to the head, &c.;  and at 4 p. m. the convul-
sions ceased, leaving her in a  state of coma, the pulse  rather
weak.  The coma continued during  the  night, but in the
morning of the 28th, she revived a little, began to swallow li-
quids, and seemed to take some notice of those about her.—
During the day,  she generally  lay with her  eyes open, and at
times appeared to follow objects with them, but showed little
appearance of sensibility, except that once or twice she named
her sister; pulse nearly of the natural standard, and  rather
weak. She took laxative medicine, by the operation of which
she seemed to be relieved, but recovered no farther intelligence.
In the night, the convulsions returned in a slighter degree than
formerly, but  were  very frequent, sometimes  occuring every
15 minutes.
   (29th) She  was in a state of coma, with  appearance of ex-
haustion, incapable  of swallowing, eye insensible, pupil na-
tural, pulse feeble and  of natural  frequency;  after mid-day,
she recovered  the power of swallowing, but soon lost it again.
In the evening, the convulsions returned, with rapid  failure of
strength, and she died in the  night.  No paralytic  symptom
had been observed, and the convulsions seemed to affect equal-
ly the whole body.
   Inspection.—iA small quantity of fluid escaped in  opening
the dura mater.  On the upper surface of the brain, there was
a slight appearance of ecchymosis, forming three small patches.
On cutting into  the left  hemisphere, there  was  found in the
upper part of  it  a round defined portion of. the cerebral sub-
stance of a dark  red colour; it was about the size of a walnut,
distinctly  circumscribed, and surrounded by healthy cerebral
substance.  In its structure, it did not  differ in firmness from
the other parts of the brain; when cut across,  it presented in-
ternally the  appearance of innumerable small red points, inter-
spersed with yellow points, but  the red the most abundant.
It was situated above the level of the ventricle, about the cen-
tre of the hemisphere; and, in the very same situation in the
right hemisphere, there was another diseased part exactly simi-
lar, except that  it was a little softened in the centre.   The
brain in other respects was healthy, and there  was ho effusion
in the ventricles.  The arachnoid of the base was remarkably
vascular on the  right side; the cerebellum was  healthy.  In 
62        INFLAMMATION OF  THE  HEMISPHERES.
the centre of the medula oblongata, there was a  small  dark
portion, as if produced by a drop or two of extravasated blood.
This  remarkable case I saw along with  the late Dr. George
Wood.

  The following  case seems  to be referable  to  this class;
showing the disease in  a stage somewhat more advanced, with
the first approach towards softening.

  Case XXVI.—A  gentleman aged 36,  of very intemperate
habits, had suffered  repeated attacks of a nature allied to de-
lirium tremens, but occasionally accompanied with symptoms
of an apoplectic character.  In October 1829, he had recently
recovered from one  of these  attacks, and  was in  excellent
health ;  went to the  country, and was  amusing himself  with
coursing, when, on  the 6th November, he was affected  with
a slight  epileptic fit.  He had a second attack on the 7th, af-
ter which he became considerably incoherent in his conversa-
tion, and he had a third and more  severe  paroxysm on the
8th, in his carriage, on his way to Edinburgh.   After the usu-
al treatment, he was  much better on the 9th, 10th, and  11th.
On the 12th, he was  excited and restless, walking frequently
up and down stairs  without any object;  and in the evening
he had a slight return of convulsion.   On the 13th he was
confined to bed, and was slightly incoherent.   He was  again
attacked with convulsion at night.   On the  14th he was  more
incoherent;  and in the night had a very severe attack, in which
he continued in a state of constant convulsion for several hours.
Pulse frequent and  weak.   On his recovery from  this pa-
roxysm, he remained speechless and with a  degree of paraly-
sis of the right side ; but he seemed to recognise those about
him, and made attempts to  express himself.—15th and  16th,
continued in the same condition.—17th, there was an increase
of the paralysis and the pulse became more feeble.   He  now
sunk into perfect coma and died on the 19th.

   Inspection.—On raising the brain a very peculiar appearance
was presented by the middle lobe of the left hemisphere, which
was over its  whole  surface of a very deep  dark-red colour
nearly purple.   On cutting  into it, the same colour was found
to extend through its substance, and in a  slighter degree into
the contiguous portions of the anterior and middle lobes where
it was gradually  lost in the healthy texture.   The part  thus 
CHRONIC FORM.
63
affected was sensibly softer than the sound cerebral substance,
but not disorganized or broken down.  There was some fluid
found in the base of the skull, but the brain in other respects
was entirely healthy.


       § II.--THE  AFFECTION IN A CHRONIC FORM.

  Case XXVII.—A  young lady aged 22, was  taken ill on
the  20th of February, 1817.  For the first week, her complaint
had the appearance of continued fever ;  in  the second week,
the  pulse came down, and the tongue became clean and moist,
while the headach continued  severe, with a sense of weight,
much throbbing in the  head, a look of great oppression, and
occasional vomiting.   Bloodletting, purgatives, blistering, and
the  application of cold, afforded partial relief; but, on the 5th
of March, the pain returned with great severity, accompanied
by  violent  throbbing,  and a degree of squinting.  The same
remedies again procured an interval of partial relief; the pain
was not removed, but  it was less  severe than  in the violent
paroxysms ; there was constant throbbing in the head, and  a
look of much oppression; the pulse varying from 84 to 90.
On  the 11th, there was a  violent  paroxysm of headach, fol-
lowed by convulsion ;  she was again relieved by bleeding, but
on  the 15th, she had loss  of recollection, much confusion  of
thought, difficulty of articulation, and numbness  of the right
arm and right side of the face,—most remarkable  in the latter,
which had no feeling when it was touched.   These symptoms
disappeared on the  following day, but the  pain continued  to
recur in  paroxysms ;  and, about  the  24th, had assumed  so
much of a periodical character, that, by the advice of an emi-
nent physician, she was treated with arsenic, which remedy,
having occasioned nausea, was given up after  a week.   She
then continued for a fortnight or more, in nearly the same state,
constantly  confined  to bed, and affected with frequent returns
of the pain, but without any violent attack, until the 20th  of
April, when it returned with great violence, accompanied by
vomiting, pain in the abdomen, and double vision during the
paroxysm;  the pulse was at this time natural.   From the be-
ginning of May, the complaint began to diminish in violence ;
on  the 20th, she was first able to be out of bed, and from that
time recovered  gradually.  Soon after her recovery, a large
glandular swelling appeared upon her neck, which continued 
64        INFLAMMATION OF THE HEMISPHERES.
stationary for many months.   During the summer and the fol-
lowing winter, she enjoyed tolerable health, but continued  li-
able to headach, and throbbing in the head, and required the
most cautious regimen.  In spring, 1818, she had severe pec-
toral complaints, on recovering from which, she began  again
to complain of headach, with sense of weight in the head, and
occasional giddiness.   In  the beginning of June, she had se-
veral attacks which resembled syncope, except that the  pulse
continued in good strength ; and, soon after this, she  began
to be occasionally forgetful, and  slightly incoherent.  These
symptoms were followed by a tendency to stupor, which was
relieved for a time by purgatives, and repeated blistering;  at
this  time, her pulse  was  generally from 96 to 100, and her
countenance was pale and exhausted.   As  these  symptoms
advanced, her pectoral complaints disappeared, and, after va-
rious turns of the symptoms in the head, she was found speech-
less in the morning of the  3d of July.   She lay with her eyes
open, appeared  to take notice of objects : pulse from 90 to 100
and weak, face  pale.    She continued in the same state on the
4th ; on the 5th, there  was increase of coma, with loss  of the
power of swallowing, and  paralysis of the right side.
   (6th) Recovered the power of swallowing: pulse 130; ex-
pression of the countenance intelligent;  eye natural; but she
made no attempt to speak.
   (7th) In the  same  state; took flowers in her left hand, and
appeared to  be amused  by them; right side  paralytic ;  great
obstinacy of the bowels.
   (9th) More oppressed.    (10)  Perfect coma; pulse  130.
She died in  the evening.
   Inspection.—The dura mater adhered  intimately to the left
hemisphere  of the brain,  at a  spot the size of a  half-crown
piece, about the middle of the hemisphere, near the falx.  At
this place a portion of the brain, the size of a large walnut,
was externally of a deep red colour, and this redness appear-
ed both  on the upper surface, where  the  membranes adhered
to it, and on the inner surface, where  it was in contact with
the falx.   When cut into,  this portion appeared rather  firmer
than the healthy cerebral substance, except towards the cen-
tre, where it was soft, as if approaching to suppuration.   The
external circumference of  the portion retained the deep red
colour, to the depth of about half an inch ; the central  parts
were of an ash  colour, with  interspersed portions of a dark *
reddish-brown.   On the upper surface^ where the membranes 
CHRONIC  FORM.
65
adhered to it) there was a deposion of false membrane to the
extent of the adhesion, and the dura mater, at the place of the
adhesion, was thickened and spongy ; the coats of the longi-
tudinal sinus also appeared to be thickened, at the place where
it came  in  contact with the diseased portion  of the brain.
There was no effusion in the ventricles, and no  other disease
in any part of the brain.   The  lungs were extensively tuber-
cular, and the pleura lining the diaphragm, on  the left side,
was rough and irregular, trom numerous small firm excrescences
on its surface, resembling warts.

   Case XXVIII.—A lady aged 60, for whose  case I am in-
debted to Dr. Hay, in  the end of September, 1824, suffered
an apoplectic attack with partial  paralysis of the right side.
She was relieved by bleeding, and appeared to be recovering
favourably, until the 8th of October, when she had another at-
tack.   She did not then become  insensible, but  complained
of a strong pulsation over the body, particularly on the right side,
the arm and leg of which were  again considerably paralysed.
From this time) she gradually lost the power of these parts,
first of the leg and then of the arm ; she had occasional returns
of the feeling of pulsation, and frequently applied  her hand to
the right side of her head, in which she said she felt uneasiness,
and to which it was  observed, that, during  sleep, her hand
was  frequently carried ;  the  bowels were extremely torpid.
The usual treatment was employed by Dr. Hay, in the most
judicious manner, without  relief; her strength  gradually de-
clined, and she died on the 26th of December, having fallen
into a comatose state, with loss of the power of swallowing,
about a week before her death.
   Inspection.—The dura mater was found to adhere very firm-
ly to the brain, at a spot about the  centre of the left hemis-
phere, on the upper part.   The substance of the brain beneath
this portion seemed firmer than  natural, and) when cut  into,
was of a bright red colour.  This portion was about an inch
and a half in extent downwards, and of nearly the same breadth;
and the cerebral substance surrounding it appeared more vas-
cular than the other parts of  the brain.   Deeper  in the sub-
stance of the brain, a similar portion was met  with, the size
of a hazel nut, which was of a deeper red colour than the for-
mer.  The corpus striatum of the same size was of a red co-
lour, inclining to purple, soft  in its  texture,  and  presenting,
when cut across, numerous points of vessels.  The right hemi- 
66        INFLAMMATION OF THF  HEMISPHERES.

sphere was healthy ; there was a small quantity of fluid in the
laterial ventricles ;  and, in both ventricles, the chorid plexus
was turgid with blood, and  contained in its substance nume-
rous small cysts of a bluish colour.  The vessels on the surface
of tba left hemisphere, and betwixt the convolutions, were
very turgid with blood; and, in some of the deeper convolu-
tions, there was a slight appearance of ecchymosis.


 § III.—The inflamed mass passing into ramollisse-
                         ment.

  Case XXIX.—A girl aged 7, had been falling off for about
two months before  her death, having some cough, with  con-
siderable emaciation;  but  her appetite  was good.  On the
22d of July, 1826, she had pain in the bowels, with diarrhoea,
and some vomiting.  These  symptoms were relieved by the
usual  remedies, but she still complained  of pain in her bowels,
and had some cough.  Three or four days after this, she com-
plained  of  headach, and her speech was sensibly impaired;
about this time, also, she complained of pain in the right ear.
Some peculiarity of speech had been observed before on one
or two occasions, when she was  able to go about.  On the
27th,  she was first  seen by Dr. Beilby, who found her affected
with headach and pain of the ear; with  considerable embar-
rassment of speech, and a small frequent pulse.  On the two
following  days, she was  considerably relieved in regard  to
pain,  and the symptoms assumed more the character of con-
tinued fever.   I saw her on  the 30th, when there was consi-
derable coma, so that she could scarcely be made to answer a
question;  pulse 90;  the  pupil much dilated, and there had
been considerable return of headach.  On the 31st, she was
speechless, with  nearly perfect coma; pulse 80.   She  con-
tinued in the  same  state on the 1 st of August, with the  pulse
becoming frequent.  On the 2d, she began to be affected with
paroxysms of convulsions, which attacked only the right side
of the body.  The  limbs of the left side appeared to be  para-
lytic,  or at least were never  observed to move, even during
the  convulsions of the right side.  These paroxysms continu-
ed to  recur for four or five days ; she then sunk into a state of
perfect coma, and  died on the 10th. She  had retained the
power of swallowing  liquids when they were put into her 
PASSING into ramollissement.
67
mouth, and seemed to recover a slight degree of motion of the
left arm.
   Inspection.—On removing the dura  mater, several  patches
of false membrane were found on the outer side of the right
hemisphere, chiefly at the openings of the convolutions,and dip-
ping down considerably betwixt them.  On cutting through this
hemisphere, a defined portion was met with in  a state  of re-
cent inflammation, presenting a uniform red colour, and a na-
tural consistence.  It was about 2i  inches in length, extend-
ing from  before backwards, about an inch in breadth, and as
much in thickness.   At its interior part, it was connected with
another portion,  about an inch in extent in all its dimensions,
in a state of perfect ramollissement,  and of a yellowish  white
or ash colour; and the two  structures evidently passed into
each other, the inflamed portion becoming gradually softer as
it approached the softened part.  Along the whole of that part
of the hemisphere, through which the inflamed mass extended,
all the convolutions were firmly glued together through their
whole extent, by a deposition of very  firm adventitious  mem-
brane ; and there was a similar adhesion of the anterior to the
middle lobe.   There was slight effusion in the ventricles, but
the central parts were healthy.   In  various parts of the brain
very minute tubercles were observed ;  and, on the base  of the
brain, at the junction of the left crus cerebri with the tuber an-
nulare, there  was an irregular tubercular mass of considerable
extent, mixed with  adventitious membrane.  In  the  lungs
there were  numerous  minute tubercles,  all in a solid  state.
In the mucous membrane of the intestines, especially at  the
lower extremity of the ileum, there  were observed  numerous
minute black spots, each of which, when viewed by a lens,
appeared to be surrounded by a minute circle of inflammation.

   Case XXX.—A lady aged 24, had long been liable to se-
vere attacks of headach, which occurred at irregular intervals,
and were excited by various causes, such as warm rooms, and
bodily exertions, and for which she had used a variety of treat-
ment with little benefit.   They had  not, however, affected her
general health, and she was recoveringfavourably from her se-
cond accouchment, under the care of Dr. Mackintosh, when,
about the beginning of the second week, she was seized with
severe headach, and considerable oppression.   She was bled
with  relief,  and continued-  tolerably  well for  several  days,
though with occasional complaint of headach.   On Sunday, 
68        inflammation  of the hemispheres.

14th January, 1827, after a disturbed night,with some delirium,
she complained in the course of the day of slight uneasiness
in her head, and a peculiar feeling of numbness in the back of
the head and neck ; but she was otherwise well and  in good
spirits, till about ten o'clock at night, when she suddenly com-
plained of numbness  and  loss of power of the  right hand.
These  feelings spread rapidly along the arm, which very soon
became entirely paralytic,  and  this was speedily  followed by
loss of speech, and twisting of the mouth.   She was immedi-
ately bled, and when I saw her soon after the bleeding, I found
her with a look of intelligence, but  without any attempt at
speech;  the  pulse quick  and feeble, the  right arm  entirely
powerless, and with a degree of spasmodic rigidity.  A few
hours after, the right leg became also paralytic.  She continu-
ed without any further change till  about three o'clock in  the
morning, when she  was seized with severe and general con-
vulsion, affecting both sides of the body, but strongest on the
left side.  The convulsion returned three  times betwixt this
and mid-day of the 15th, after which the attacks became much
more frequent;  and from this time she showed no appearance
of sensibility.   She had from the first  swallowed with difficul-
ty, but every attempt to make her swallow now excited gene-
ral convulsion.   During the attacks, the face was much dis-
torted, and equally so on both sides ;  the limbs of the left side
were  violently convulsed,  while  the right arm  was  affected
chiefly with a rigid spasmodic contraction, and  a tremulous
motion.   The convulsions now returned with great  violence
and frequency, sometimes every half hour, and  each attack
continued for ten or fifteen minutes.  The pulse was generally
rapid ; sometimes extremely feeble, and sometimes of tolera-
ble strength. • The breathing was sometimes  frequent and
convulsive, and sometimes slow and oppressed, as if she were
moribund ; and on many occasions she was considered as be-
ing within a few  minutes of death; but she continued to live
in this state till  the  evening  of the  16th, being forty-eight
hours from the  attack.  On the second day, the rigid  contrac-
tion of the right arm had  disappeared, and it continued  en
tirely  paralytic, except when  it was affected by the  convul -
sion.
   Inspection.—On  the upper  surface  of the  left hemisphere,
and between the convulsions, there was a considerable ecchy-
mosis, produced  by a very thin layer of extravasated blood
betwixt the arachnoid and pia mater.   The veins on the upper 
passing into ramollissement.
69
part of this hemisphere were remarkably turgid, and were found
to be distended with dark blood in a perfectly firm fleshy state,
mixed with some firm white matter;  and their coats appeared
to be thickened.   Where these veins entered the longitudinal
sinus, there was a remarkable diminution of its area, arising
partly from the thickening of its coats, and  partly from depo-
sition of firm white matter on its inner surface.  In  the sub-
stance of the left hemisphere, about the centre of its long di-
ameter,  towards the outer  side, and  rather  above the level of
the ventricle, there was a distinctly defined  portion about the
size of  a small walnut in a state of  complete ramollissement,
but retaining entirely the natural white colour;  and immedi-
ately bordering upon this part, there was a considerable  por-
tion in a state of the deep redness described in the former cases ;
the brain in other respects was healthy, except a small soften-
ed spot  in the right hemisphere.
  This  important case was  also seen by the late Dr. Kellie,
and Dr. Scott.
   § IV.—Extensive ramollissement of the corpus
                       striatum.

  Case XXXI.—A man  aged 25, about four years  before
his death, was first affected with difficult breathing, strong ac-
tion of the heart, dropsical symptoms, and irregular pulse ; af-
ter some time he was considerably  relieved, but about  a year
and a half after this he again became dropsical, and about this
time was suddenly seized with palsy of the left side of the body,
delirium and coma.  The  coma  subsided in a few days, and
he recovered the use of his limbs in a few weeks, so that he
was able to  return to his work as a joiner.  The symptoms in
his chest, however, soon obliged him to give it up, the strong
action of the heart continuing, with small irregular pulse, and
much dyspnoea.   In May  1821, he was again attacked with
palsy of the  left side, accompanied by coma and delirium, and
recovered in a few weeks.  In these two  attacks of palsy,
there never had been any complaint of headach ; but in March
1823, he was attacked with severe headach, followed by loss
of memory, palsy of the left side, and coma.   He again reco-
vered in  a  few  weeks, so as to be able  to walk about;  the
symptoms in the thorax continued as before.   20th October
1823, he was a fourth time attacked with palsy of the left side, 
70       inflammation of the hemispheres.
accompanied by violent pain referred to a particular spot on
the coronal suture, a little to the right side.   This was follow-
ed by maniacal delirium, the  pulse  feeble and  irregular, the
mouth twisted, and the left eye  distorted.   After some  time
he recovered considerably, so as to be able to walk with  a lit-
tle assistance,  dragging his leg, but continued to be occasion-
ally delirious till a few days before his death, when the palsy
again became complete, with much  delirium, and some  con-
vulsive  affections, but  no  coma.  He died  on the 17th  De-
cember.
  Inspection.—There  was nothing unusual  on the  surface of
the brain, and  no  effusion in the ventricles.   The right corpus
striatum  was externally of a peculiar dull yellow colour, and
when cut into was found to be throughout its whole substance
in the extreme state of ramollissement, extending to a  great
depth; this  was mixed with a  slight appearance of pus, and
the soft undulating mass was separated from the ventricle by
a delicate membrane.   There was also ramollissement, but of
small extent in the left corpus striatum.   The heart was ge-
nerally and considerably enlarged ; the right ventricle  thick-
ened ;  the left  ventricle enlarged without thickening;  the left
auricle much enlarged, and containing a large organized po-
lypus firmly attached to its sides, and deposited  in  successive
layers like the  deposition in the sac of an aneurism.


§ V.—The affection in a  chronic  form, with ramol-
  lissement  OF SMALL  EXTENT, AND REMARKABLE  SYMP-
  TOMS.

   Case  XXXII.—A gentleman aged 26, of a plethoric habit,
had suffered occasionally for two or three years from headach
and vertigo, which were always relieved by depletion.   On
12th April, 1827, while walking out, he was seized with con-
fusion and giddiness, embarrassed speech, and  a considera-
ble degree of paralysis  of the right leg.   He was rather pale;
his pulse was  70  and soft; and  he  did  not complain  of any
headach.  The usual treatment was  adopted with activity by
Dr. Combe of  Leith, without much relief.  On the contrary,
after several days  he began to complain of acute  headach ac-
companied by  vomiting and hiccup ;  and the other symptoms
continued nearly as before,—his  speech being laboured   and
slow,  and his  memory very  defective*  After  some  weeks 
CHRONIC, WITH RAMOLLISSEMENT,  ETC.       71
these symptoms subsided, so that he was able to walk out;
but the headach continued with frequent vomiting.   The pain
was chiefly referred to the left side of the head, sometimes to
the occiput, and there was occasional numbness of the right
arm.  When I saw him, along with Dr. Combe and Dr. Kel-
ly in July, his chief complaint was of frequent and  irregular
attacks of vomiting, occurring  daily, or repeatedly during the
day.  It came on very suddenly, without previous nausea, and
he was often awaked in the night by the sudden attack of vo-
miting.   He had  now a pale sickly look; there was no para-
lytic affection, and little complaint of headach ; though he still
had occasional uneasiness in the  head, sometimes referred  to
one part of it and sometimes to another.  When he did refer
it to a particular part as the principal seat of  the pain, it was
either the left temple or the occiput.  But the headach at this
time was slight and transient, and the  symptoms in the sto-
mach were so much the more prominent, that it was a matter
of  much doubt whether there  was now any fixed disease  in
the head.  The vomiting was much relieved by  the subnitrate
of bismuth, so that he was free from it for several days.  But
it soon returned and went on as before, with increasing debili-
ty,  great listlessness, and  bad  appetite; pulse little affected.
He had now a peculiar  unsteadiness of his limbs, so that on
first getting up into a standing posture, he staggered very much
and required some time and attention to steady himself. When
he had accomplished this he walked with tolerable  firmness.
The symptoms went on in this manner till the 27th of October,
when he was suddenly seized with violent 'and continued con-
vulsion,  and died in nine hours.
   Inspection.—In the substance of the middle lobe of the left
hemisphere of the brain, about the level of the lateral ventri-
cle, there was a portion in a state of  complete ramollisement,
about an inch and a half in length, and an inch in its other di-
mensions, and the neighbouring parts appeared unusually vas-
cular.   The tuber annulare and pons Varolii were softer than
usual, but otherwise healthy.  No other morbid appearance
could be discovered in the head, and all the other viscera were
healthy.
   It is unnecessary to point out the very remarkable features of
this case. The sudden attack so closely resembling the ordina-
ry paralytic attack, must have been connected with the com-
mencement of the inflammatory stage. The  remarkable symp-
toms in the stomach in the farther progress of the disease, and 
72       INFLAMMATION OF THE HEMISPHERES.
the mode of its termination, make it altogether a case of great
value in the pathology of this remarkable affection.   The fol-
lowing case shows the  same morbid appearance, with a train
of symptoms considerably different, but with a remarkable si-
milarity in the mode of its termination.

   Case XXXIII.—A gentleman aged 38, during two  years
before his death had suffered several epileptic attacks, from
which, however, he had always speedily recovered.  On the
morning of the 27th December, 1827,  he was found in bed
speechless and paralytic on the right side.   He recovered his
speech in the course of the day ; the palsy continued in the
usual manner, and after some time he began to recover a de-
gree of motion of the parts.   When he  came to Edinburgh
about a month after the attack, he had  recovered the use of
his leg so far as to be able to walk once or twice across his
room with much exertion ; his arm was  improved in a  much
less degree; his speech was distinct, but his mouth was con-
siderably distorted, and his mind was somewhat impaired. He
now consulted Dr. Thomson, and under the  usual treatment
he was progressively improving, so that at the end of another
month he could walk along the streets to a considerable dis-
tance, though with a dragging motion of  his leg, and  could
nearly raise his arm to  his head.   In the evening of 22d Fe-
bruary he went to a supper  party, and seemed remarkably
well; but departed considerably from the abstemious regimen
to which he had been previously restricted.  About 8 o clock
in the morning of  the 23d  he was found in bed in a state  of
complete insensibility, accompanied by severe and general
convulsion, which  was  strongest in the limbs of the right side.
The face was  much convulsed, the eyes rolling and insensible,
the respiration laborious  and convulsive.   Bloodletting and
the other usual means were actively employed without any re-
lief.   The  convulsion  continued  unabated in the state now
described, when I saw  him at eleven, and he died at two.
   Inspection.—The brain externally was healthy, except some
old adhesion of the membranes near the posterior part of the
falx, and very trifling effusion under the arachnoid.   The ven-
tricles contained the usual  very small quantity of fluid.  On
the outer side of the left ventricle, and separated from it by a
thin partition of healthy cerebral substance, there was a defin-
ed portion  in a state of complete and diffluent ramollissement.
The portion thus affected was about an inch in depth ;  about 
          CHRONIC, WITH RAMOLLISSEMENT, ETC.       73

half or 3-4ths of an inch in diameter at the  upper part, and
became gradually narrower as it descended by the side of the
ventricle, until it terminated almost in  a point.   There  was
considerable softening of part of the medulla oblongata, and
the upper part of the spinal chord.   'No other vestige of dis-
ease could be discovered on the most careful examination.
  I do not attempt to offer any explanation of the symptoms
in these two most remarkable cases, or to reconcile them with
the old  notions in regard to diseases of the  brain.  I give
them as facts carefully ascertained, and faithfully related, to
be illustrated by farther observations on this  very remarkable
disease.
§  VI.—The  affection in a  chronic  form,  with  ex-
   tensive ramollissement, AND, REMARKABLE DISEASE OF
   THE BASILAR ARTERY.

   Case XXXIV.—A young man aged  18, had been for six
or eight weeks affected with cough and pain of the chest, and
was supposed  to be phthisical; but for several days he had
been much better, when on the 15th December 1819, he sud-
denly fell down deprived of  sense and motion, and  paralytic
on the left side, with twisting of the mouth.  When partially
recovered, he complained of severe pain in the right temple;
his speech was  very  indistinct; countenance  expressive  of
great stupor.   The usual treatment was actively employed, but
without much benefit, and he continued for about ten days
with little or no improvement; the left side perfectly paralytic ;
a great degree of coma ; the speech  very  indistinct; but  he
still pointed to the right temple as the seat of fixed uneasiness.
During this time his pectoral complaints had disappeared.  In
January 1820, he began to improve, so as to have  less unea-
siness in his head, and considerable motion of the leg, but the
arm continued entirely paralytic.   His cough  now returned,
with considerable pain in the right side of the chest.  He con-
tinued without farther change till the  15th of February, when
he complained of pain in the back of his head, and  was seized
with loss of speech, and of the  power  of swallowing.  He
soon recovered his speeeh, but the power of swallowing was
permanently lost, so that from this time he  was constantly fed
by liquids introduced into the stomach through an elastic gum
tube.   He  was now quite distinct, and  did not Gomplain of
                            10 
74        INFLAMMATION OF THE  HEMISPHERES.

any pain ; the cough again abated; pulse of natural frequency,
but feeble.  In the beginning of March he seemed to improve
a little in strength, so that he was several times taken out in
a carriage ; there was considerable  motion of the left leg, but
the arm continued perfectly paralytic ;  no return of the power
of swallowing; speech and intellect entire.  He died rather
suddenly on the 20th of March, having the day before become
extremely weak and pale without any obvious cause.
   Inspection.—On removing the dura mater, there appeared
on the middle of the right hemisphere a remarkable depression,
which, when cut into, was found to arise from an extensive
mass of pure ramollissement; the part being in the state of a
soft white pulp, without any appearance of pus, and without
fetor; it extended  the whole depth of the hemisphere.  In
the cerebral matter adjoining to this disease, there was a small
abscess, no larger than a bean, lined with a firm soft cyst  of
coagulable lymph.   There was very little effusion in the ven-
tricles, and no other disease in the substance of the brain. On
raising the brain, a remarkable appearance was found in the
basilar artery;  through the extent of about an inch it was very
much enlarged and  hard, and this  portion was found  to be
completely filled up by a firm white matter without any ap-
pearance of blood.   Anterior to this portion, there was a small
coagulum of blood in the artery.   The lungs  were tolerably
healthy, but there was a considerable deposition of coagula-
ble lymph, forming a  thick firm mass betwixt the right lung
and the pleura costalis at the lower part immediately above the
diaphragm.


§ VII.—Ramollissement  combined with  suppuration.

   Case XXXV.—A  man aged 24, had been  liable for two
years to headach, which was always referred to the right side
of the head.  In February 1818, he contracted syphilis, which,
being  neglected, became  inveterate,  and continued fourteen
months.   During this time the headach became more severe,
and was always referred to the right temple.  In June  1819,
he was affected with numbness of the left thumb, which gra-
dually extended over  the arm, and he had afterwards complete
paralysis  of the left arm and leg, with severe pain in the right
temple.   This was followed by maniacal delirium, which con-
tinued for three days.   He was relieved by copious bleeding, 
        with  ramollissement and suppuration.      75

&c, and was completely recovered within a month.  In Au-
gust, he was affected in the same manner, and again entirely
recovered.  He continued well till 27th November, when he
complained of violent pain over  the whole head, and in the
night was observed to have lost his speech and the power of
his left side; the jaws were  locked; he appeared sensible,
and expressed his feelings by signs; pulse 98, small and ir-
regular.  There  was no change  on the 28th; on  the 29th,
the body was rigid as if tetanic; he  then became comatose,
and died in the evening.
   Inspection.—The anterior and lower part of the right hemis-
phere was extensively diseased, forming a mass in which  soft-
ened cerebral matter was mixed with  pus of intolerable fetor.
There was very little fluid in the  ventricles, and no  other dis-
ease could be detected in any part of the brain.


           § VIII.—Undefined suppuration.

   Case XXXVI.—A gentleman aged 18, had been for many
years affected with a considerable degree of deafness, and had
been liable to suppuration of the ears.   In 1810 he was affect-
ed with a chronic abscess behind the left ear, by which a probe
could be  passed to a great depth  into the cells of the mastoid
process.   This sore  discharged  more  than a year and  then
healed, leaving a deep cicatrix.   From this time he was lia-
ble to headach, which became more severe in the  beginning
of the year 1813.
   May 14, 1813, after having been  for some days languid,
and complaining a little of his head, he was seized with severe
headach and frequent vomiting.   He was much  oppressed,
and lay in a dozing state, impatient of being disturbed; pulse
60.  He was treated  in the usual  manner, by free, general,
and topical bleeding, purgatives, blistering, &c.  On the  15th
the headach was still  violent, but the  vomiting  had abated;
pulse 60; had several severe attacks of shivering, was op-
pressed and disposed to  sleep,  but  sensible; eyes natural.
(16th)  Headach relieved ; increasing oppression.   From this
time he lay in a state of partial  stupor, with  much talking,
which was generally coherent; pulse varying from  80 to  120.
He died on the 22d, rather unexpectedly, and without perfect
coma.   He had continued to know the persons about him till
about twelve hours before his death.  His sight continued na- 
76        inflammation  of the hemispheres.

tural except on the day of his death, when he appeared to be
blind :  no paralytic affection, and no convulsive symptom had
been observed.
  Inspection.—The right  hemisphere of the brain, to about
half its depth, was entirely reduced to a mass of fetid pus; in
the centre  it was fluid, and  towards the external parts it was
more of a pulpy consistence.  In  this mass, there were found
some small coagula of blood, and the ventricles contained a
considerable quantity of bloody fluid.

  Case XXXVII.—A gentleman aged 18, (10th July, 1815,)
was affected with violent headach, extending along the upper
and back parts of the head, and accompanied by severe pain
in the neck, where it was much increased  by the motion  of
the head.   There was much oppression ;  pulse natural; face
rather pale;  tongue  clean ;  eyes  natural.  He had been  ill
three days, and the complaint had commenced with shivering;
he had been many years affected with deafness, and liable to
suppuration of the ears.    The usual  practice was  employed;
general and topical bloodletting,  purgatives, blistering, &c.
  The bleeding gave great relief at each repetition of it, and the
blood was sizy; but the relief was transient.   On the  13th, he
had squinting and double vision, which continued on the 14th,
but then went off and did not return.   The headach continued
with many variations in  degree; sometimes he made little
complaint, and at other times, was in violent pain;  there was
sometimes a degree of delirium, but it was slight and transient;
there was much oppression  but no  coma, and no  paralysis.
He died  on the 17th rather  suddenly.  At my last visit, he
had raised himself in bed with little assistance, answered ques-
tions distinctly, and knew every person about him ; pulse 60;
sight natural.   His death  occurred a few minutes after I had
left the house.
  Inspection.—The whole of the posterior part of the  left  he-
misphere of the brain was one mass of undefined suppuration.
There was considerable  deposition of coagulable lymph on the
surface of the brain in  several places, especially under the  an-
terior lobes.   There was a very small quantity of fluid  in the
ventricles, and considerable ramollissement of the fornix.   In
the substance of the brain, near the base, there was  a small
tumor of  an  ash-colour, which contained  a cheesy matter ap-
proaching to  suppuration.   A portion of the dura mater  co-
vering the temporal bone behind the auditory portion was 
with undefined suppuration, etc         77
thickened and spongy, and there was slight appearance of ca-
ries in the portion of the bone with which the diseased  mem-
brane was connected.
  Dr. Bright has described a remarkable case, in which a mass
of this kind of undefined  suppuration occupied nearly the
whole of the right hemisphere.  The case  began with puer-
peral convulsions, after which the  patient lay for seven days,
with very obscure symptoms, and  sensible, till she died sud-
denly after violent convulsion.


§ IX.—Extensive undefined suppuration with extra-
                    VASATED BLOOD.

  Case XXXVIII.—A man aged 40, had complained for two
months of frequent pain and throbbing in the left side of his
head.  In March 1814, he began  to be affected with convul-
sive motions in the right arm and  leg, which attacked him in
paroxysms,  and usually continued  about a minute, leaving him
in the intervals  able for his usual empfoyment as a blacksmith.
After bloodletting and purging, these paroxysms became less
frequent, and after  eight or ten days ceased.   He  was then
affected with giddiness and  confusion of thought, and  consi-
derable torpor of the right side.  After some time, this was at-
tended with  motions, in the  right arm and leg, exactly resem-
bling those  of  chorea.  The muscular power of these parts
was at  the  same time  diminished,  and, at the end of two
months from the first appearance of the spasmodic  affections,
the arm and leg became entirely paralytic.   His speech was
then affected, being first inarticulate, and afterwards gradually
lost, so that  after the middle of June he never was able to ar-
ticulate a word. His  pulse, which till this time had continu-
ed quite  natural, now became a little frequent;  he passed his
urine and feces involuntarily, but  his mental faculties seemed
to be entire.  He took food when it was offered him, and put
out his  tongue  when  desired;  his eye was  natural, and the
expression of his countenance intelligent.   His sight and hear-
ing appeared to be perfect, but he never  attempted to  speak.
He often screamed  as if from pain,  at the same time  laying
his hand on his forehead, and frequently shed tears.   He con-
tinued in this state till the end of July, when he became coma-
tose,  and died in three days.
   Inspection.—On removing the  dura mater, the1 left hemis- 
78        inflammation of the hemispheres.

phere of the brain felt soft and fluctuating through its whole
extent like a bag of fluid; on cutting into it, there was about
half an inch in thickness of sound cerebral substance, the re-
mainder of the hemisphere was found nearly reduced to a fluid
mass, partly consistent of purulent matter, and partly of cere-
bral substance, in a soft pulpy state ;  but the greater part was
purulent.   From this mass of disease, the ventricle was sepa-
rated merely by the membrane which lines it, and contained
a small quantity of serous fluid.  In the substance of the left
thalmus, there was a coagulum of blood, of the size of a wal-
nut.
             § X.—The encysted abscess.

  Case  XXXIX.—A girl  aged 11, thin and delicate, after
having complained for some days of headach, was seized on
the  11th of January, 1817, with convulsion, which continued
about half an hour.  I saw  her on the 12th, and found her af-
fected with severe  heSdach, and paralysis of the right arm,
which had taken place immediately after the convulsion.  The
pulse was 100; the tongue  foul; the face rather pale, and the
eyes languid.  Being bled from the arm and purged, and cold
being applied to  the head, she was much relieved.  On the
13th, the pulse was natural, the headach was much abated,
and she had recovered considerable motion of the arm.  On
the  15th, the headach being increased, and the arm more pa-
ralytic, she was  bled again;  and on the 16th and  17th, she
was much relieved, the pulse  natural, and the motion of the
arm much improved.  On the 18th,  after  being, affected with
increase of headach, and some vomiting, she became convuls-
ed,  the convulsion  being confined entirely to the head  and
right arm.  The head was drawn towards the right side with
a rolling motion  of the eyes, the arm was in constant and vio-
lent motion ;  she was sensible, and  complained of headach;
pulse 100.   Being bled to 8 ounces the convulsion ceased in-
stantly, and the headach was relieved, but the right arm con-
tinued in a  state  of complete  paralysis.   (19th and 20th)
The arm had recovered  a little motion \ some  headach con-
tinued, with  occasional  vomiting; pulse 60.  On the three
following days, the convulsive attacks returned several times;
they did  not now  affect the head or face, but  were entirely
confined to the right arm, which, after the 23d, was left in a 
WITH ENCYSTED ABSCESS.
79
state of permanent paralysis.  Hitherto no other  part of the
body had been affected by the convulsion; but on the 24th,
it attacked the right thigh and leg, and left them in a state of
paralysis; pulse 60.  The former remedies were again em-
ployed with activity, without any effect in arresting the pro-
gress of the disease.   The thigh and leg now went through a
course precisely similar to that described in regard to the arm,
and on the 29th, remained in a state of permanent paralysis.
When the convulsion first began to affect the leg, the arm was
affected at the same  time ; but afterwards it was confined to
the thigh and leg, the arm remaining motionless.
  February 4th.  Complete paralysis of the whole right side;
no return  of convulsion; she continued quite  sensible, and
made little complaint;  pulse  from 50 to 60.  She now con-
tinued  for several  days without  any change, and except the
palsy of the right side,  every function was  natural.  She was
quite  sensible, appetite good, pulse and vision natural, and
she made little complaint of any  uneasiness.  She was, how-
ever, inclined  to lie without being disturbed, and gradually
became more oppressed.  On the 11th, this  had increased to
perfect coma, in which she continued for three days, and died
on the  14th.
  Inspection.—In the upper part of the left hemisphere of the
brain, there were two distinctly defined abscesses, containing
together from six  to eight ounces of very fetid pus.   They
were lined  by a firm white  membrane, and a thin septum of
firm white  matter  separated  them from each other; the one
was in the  anterior part of the hemisphere, very near the sur-
face, and the other immediately behind it; they had no com-
munication with each  other, or  with the  ventricle.   In the
posterior part of the right hemisphere, there was  a small ab-
scess containing about half an ounce of pus.  There was no
serous effusion in any part of the brain, and  no other morbid
appearance.

   Case XL.—A gentleman aged  21, had been  for  many
years  affected with cough and puriform expectoration, which
was often in considerable quantity;  he had also had repeated
attacks of haemoptysis,  some of tiem copious.  He was stint-
ed in his growth, and of a feeblenabit, but in other respects
enjoyed tolerably good  health, and was able to attend  to his
business as clerk to a solicitor, till the beginning of July 1822,
when he began to complain of headach.   For some time be- 
80        INFLAMMATION OF THE HEMISPHERES.
 fore this he  had observed occasionally, while sitting at his
 desk, a deficiency of sight, but had taken little notice of it.
   This illness began with headach, loaded tongue, and quick
 pulse, and so continued for eight or ten days without exciting
 any alarm.  He was treated in the most judicious manner by
 Mr. Johnston, and  seemed to be recovering gradually,  the
 pulse  coming down, and the headach being considerably re-
 lieved, though not quite gone..  I saw  him about the 15th.
 The pulse  had then fallen to 50, he was feeble and languid,
 with some headach, and a look of oppression.  The pupil was
 rather dilated; there was an evident imperfection of vision,
 and about  this time there was first observed a weakness of the
 left arm and  leg.   The  headach had  been at first referred
 chiefly to the left side of the head, but now it was principally
 on the right side, though he often described it as extending
 across the  forehead.   The cough continued, with considerable
 expectoration of a tenacious  puriform fluid.  There was no
 pain in the chest, and  no uneasiness in breathing, but the
 pulsation of the heart was felt entirely in the right side of the
 thorax.  This peculiarity had been observed for several years,
 but it  could not be  ascertained at what period it had com-
' menced.
   His pulse, was now feeble and languid, and his general ap-
 pearance  pale and exhausted.  For several days there was
 little change, the pulse continuing  about 50,  sometimes 48.
 After three or four days  there was a slight convulsive attack,
 and a second about two days after; these, however, made no
 change in  the symptoms.  About  the  24th  there was some
 incoherence, but it was slight, and soon went off.   The pupil
 was still considerably dilated, though sensible to the light;  a
 degree of headach continued, but it was  not much complained
 of.  He was now disposed to lie without being disturbed, but
 when  spoken to was quite intelligent.  About the 26th, there
 was a remarkable improvement in his appearance, and much
 less headach, the pulse beginning to rise.  (27th) Pulse 108;
 more  comatose, but sensible when  roused.  (28th)  Pulse
 120;  had  copious purulent expectoration in the morning, and
 seemed much exhausted.   He lay much oppressed, but when
 roused answered questions ^stinctly.  He  could still move
 the left arm, but slowly and With  difficulty, and with an awk-
 ward motion, somewhat resembling that of chorea, or as if he
 threw the whole arm forward by a strong effort of the muscles
 of the shoulder;  he had seldom attempted to move the leg for 
WITH ENCYSTED ABSCESS.
81
several days.   In the course of this day there was observed a
slight degree of squinting;  and he died in the night without
any other change.
  Inspection.—The brain was externally healthy.  In the up-
per and anterior  part of the right hemisphere, very near the
surface, there was  an abscess  containing  about an ounce of
very fetid pus.  In the posterior part of the same hemisphere,
there  was another abscess  rather smaller.   These abscesses
were distinctly defined, but not very distinctly lined by a mem-
brane, and the cerebral matter  surrounding them was slightly
softened.  In the anterior part of the left hemisphere, imme-
diately under the surface, and  at the very angle of it, which
lies over the orbit, there was a small  abscess containing  from
one to two drachms of pus, and another rather larger in the pos-
terior part of the hemisphere.   These abscesses were all above
the level of the ventricles, except the  one in the  posterior part
of the right hemisphere, which went  down a little behind the
ventricle.   The ventricles were  empty,  and  there  was  no
other disease  in the brain.   The right lung was reduced to a
small dark-coloured mass, resembling the spleen, and inter-
nally presented a series of abscesses, communicating with  each
other, and with the trachea.   The heart lay in contact with it
on the right side of the thorax;  and the left lung was so en-
larged as to fill all the remainder of the cavity.   It was  quite
healthy, except a small tubercular mass in a firm state, in the
upper part of it.

  The following case shows the encysted abscess with symp-
toms remarkably different from  those mentioned in the preced-
ing cases.

   Case XLI.—A man aged 43, had complained of  headach
for ten  days, but had not been prevented from following his
usual employment.   At one o'clock in the morning of the 9th
May, 1827, he was seized with  palsy of the left side of  his
face,  and became incoherent and unmanageable.  When  he
was  seen some  hours  afterwards by Dr.  Huie, these symp-
toms continued; the pupils were contracted,  and  the  eyes
were in perpetual motion ; the skin hot; the pulse 90, full and
strong.  There  was  no palsy of any of the limbs, but, on the
contrary, he  made the most  powerful resistance when Dr.
Huie attempted to bleed him, which, however, he accomplished
to the extent of thirty ounces.   In  the  afternoon there was
                            11 
82         INFLAMMATION OF THE HEMISPHERES.
considerable coma with stertorous breathing, but both these
symptoms disappeared after another bleeding.  On the 10th,
the palsy of the face was gone, but he was still incoherent
and  restless; pulse 100.   Topical bleeding was employed,
and purging with croton  oil, &c.   On  the  11th, he was  co-
herent and quiet, pulse  108; but he became incoherent in the
afternoon.  On the 12th, he was sometimes drowsy and some-
times restless; pulse 120 and small.   He  died in the night.
   Inspection.—Three abscesses were found  in the brain, all
completely encysted, and filled with well formed pus.   The
first was in the anterior lobe of the left hemisphere, and con-
tained about three drachms of pus. The second was in the pos-
terior lobe of the same hemisphere; it was considerably larger,
and  had burst into the ventricle, which was filled with the
matter.   The third was in the posterior part of the right hemi-
sphere,  and appeared to  be making its way towards the sur-
face.

   A still greater obscurity of symptoms occurred in the fol-
lowing  remarkable case, for which I am indebted to Dr.  Al-
lison.   It occurred under his care  in  the  Clinical Ward, in
June, 1827.

   Case XLII.—A man aged 26, was seized with shivering,
headach, sickness, and sudden loss of strength, with fits of
delirium in the night.   Two days after the occurrence of these
symptoms, he  was admitted into the Clinical Ward.   At this
time, he was  able to walk when supported on one side, but
with feebleness and difficulty, his legs, particularly the right,
being at each  step dragged along, rather than raised  from the
ground; his expression was dull and listless, but he said he
was free from  pain.  A few hours after, he complained of vio-
lent pain in the occiput, with frequent vomiting.  The pain
was relieved by a bleeding.   In the evening he was  oppress-
ed, and answered questions slowly and with difficulty; there
was still some headach,  with  nausea;  the  skin hot and dry;
the pulse varying from 80 to 100, sharp, and moderately full;
tongue  dry;  pupils natural; respiration somewhat short and
hurried.  About  half an hour after this report was taken, he
sunk into perfect coma, with dilated pupils, for which another
bleeding was employed without relief, and in less  than an hour
he died.
   Inspection.—The brain was externally of a reddish-brown 
ABSCESS OF THE CORPUS STRIATUM.          83
colour.   On the right side of the vertex, there was a spot the
size of a half-crown of a greenish yellow colour.  On remov-
ing a very thin portion  from this spot, an  irregular abscess
was opened, which  contained well  formed pus, and which
seemed to be entirely limited to the cineritious substance.   In
the posterior part of  the left hemisphere, on a level with the
corpus callosum, there was another abscess, which seemed to
be  seated in the medullary matter,  and was  surrounded  by
softened cerebral substance of a livid  yellow colour.  In the
posterior part of the right hemisphere, there  were two other
abscesses, one in the cortical substance, and the other in the
medullary.  Here  also a  fifth abscess was found, of a very
small size, being about the size of a  pea, but surrounded by a
more  defined cyst than any of the others;  there was exten-
sive ramollissement of the formix, septum  lucidum, and the
lower part of the corpus callosum.  The left corpus striatum
was softened, and had a greenish-yellow colour; the surface
of the left thalamus was ragged and  almost fluid, but retained
its  natural colour.
 § XI.—Abscess of the corpus striatum of very small
                        EXTENT.

   Case XLIIL—A gentleman aged 33, in January,|1817,
had a severe attack  of pneumonia with symptoms of carditis,
from which he recovered  perfectly, after having been4bled to
the extent of 160 ounces  in  five  days.   For sometime after
he felt his breathing a little uneasy, but this gradually subsid-
ed ;  and he enjoyed very good health till the middle of Feb-
ruary, 1819, when,  on awaking one morning, he found his
whole left side numb and insensible, but without any remark-
able diminution of motion.   The loss of feeling extended along
the half of his face, the line being drawn with much precision
along the  centre of the nose ;  he had no other complaint; had
no headach, and  the pulse was natural.  He was freely bled
and purged; the symptoms then gradually subsided,  and in
four or five days were  gone.   From this  time, however, his
friends remarked that he was  less  acute in business than for-
merly, and that his  memory was somewhat impaired.   In the
month of May,  this deficiency rather increased;  and, about
this time, he complained  of slight uneasiness in his head, for
which he  was again bled.   He continued, however, to attend 
84       ABSCESS OF  THE MEDULLA OBLONGATA.

to his business as a solicitor, till the 16th, when he appeared
considerably confused, and complained of his head ; his pulse
was now feeble, so as not to indicate farther general bleeding.
After  a purgative and topical bleeding, he was much relieved,
and in the evening was quite distinct and made no complaint.
About two in.the morning of the 17th, he was heard to make
a remarkable noise in his sleep, which was found to be owing
to a kind of convulsive breathing.  This was speedily follow-
ed by perfect coma, with loss of the  power of swallowing.
He lay in this state till nine  o'clock at night, and then died.
All the usual remedies had been employed without the slight-
est effect.
   Inspection.—Every part of the brain was found in the most
healthy state, till we came to  the left corpus striatum; in the
lower part of this there was a small irregular abscess, not ex-
ceeding the size of  a  small bean, containing purulent matter
of remarkable fetor. In the centre of the right corpus striatum,
there  was also discovered a minute abscess regularly and nice-
ly defined,  but no larger than a small pea.  No other disease
could be detected in any part of the body.


      § XII.—Abscess of the medulla oblongata.

   Case XLIV.—A child aged 16 months, whom  I saw only
a week  before  his  death, had been in a  declining state of
health for ten months.   The beginning~of his bad health was
ascribed to a fall, in which he was supposed to have sustain-
ed an injury of the  back part of the head or neck.  From this
time he was often  much oppressed, and had been gradually
wasting.  Three months before the time when I saw him, he
had squinting, and  appeared to lose  the power of the  right
arm and leg.  The squinting went off after some time, but af-
terwards recurred occasionally.  The use of the arm and leg
was never entirely recovered.   These always appeared weak-
 er than the limbs of the other side,  and he seldom attempted
 to raise  the arm at all.  He  had also  suffered  occasionally
 slight convulsive affections.   When I saw him there was no
 very  marked symptom, except considerable emaciation: the
pulse was frequent, and the bowels very confined. Much dark
 coloured matter having been evacuated from his bowels  he
 seemed to be relieved.  After some  days, there was a remark-
 able slowness of the pulse, and in the course of the same day 
             abscess of the cerebellum.           85

he was attacked with violent convulsion.  This recurred seve-
ral times during two days, and then proved fatal.  There was
no coma; the  eyes  continued  sensible  during  the intervals;
and he took notice of objects  a very short time before death.
  Inspection.—There were several ounces of fluid in the ven-
tricles of the brain.   In the substance of the medulla oblon-
gata, where it is  crossed by the Pons  Varolii, there was an
abscess which appeared to occupy its whole diameter. It had
the appearance of a  scrofulous  abscess, and was contained in
a cyst, the inner surface of which was of a yellow colour, and
had an appearance  of ulceration.   There  was considerable
disease in the  glands of the mesentery.


         § XIII.—Abscess of the cerebellum.

   Case XLV.—A  young lady aged 18, was seized on 4th
March, 1813, with inflammation of the bowels.  The inflam-
matory symptoms were subdued by two full bleedings, but the
bowels continued very obstinate,  and were not moved in a
satisfactory manner  till the  12th.  During this time, a  varie-
ty of purgatives had been given, with repeated tobacco  injec-
tions ; and by calomel, given as a purgative,  her mouth had
been affected as early as the 7th.
   From the beginning of the attack, she  had been affected
with pain in the left ear, and about the 7th began to com-
plain of headach.  This was at  first slight, and, amid the
urgency of her other symptoms, excited little attention.  It in-
creased, however, and on the 11th had become violent, so that
she lay pressing her temples with  her  hands,  and screaming
from pain.  The pulse was at this time natural, and she was
free from vomiting and uneasiness in the bowels. On the 11th,
there was a considerable discharge of matter from the left ear.
On the 13th,  the pulse rose suddenly to 160,  and there was
such a degree of sinking as required the use  of wine.   The
 pulse  soon subsided, so that on the evening of the 14th it was
 at 80, and on the 15th at 60.   The  headach  continued una-
bated.   On the 14th, there was  a tendency to coma,  which
 was increased on the 15th, with dilation of the pupil.   There
 was now little room for  active treatment;  and topical  bleed-
ing, blistering, &c,  were employed without relief.  On the 16th,
the pulse began to  rise again, but was very variable,  in the
course of a few minutes varying from 80 to 120.   She  lay in 
 86       ulceration of  surface of  the brain.

 a state of great oppression, but when  roused talked Sensibly ;
 headach still severe.   (18th) Had lost the power of swallow-
 ing, but often asked for drink, though  she was nearly suffo-
 cated in the attempt to swallow it; the  pulse varying from 90
 to 150.  (19th)  Squinting and dilated pupil;  pulse varying
 from 96 to  160.   (20th)  Squinting increased;  swallowed a
 little once or twice with effort; at other times was nearly suf-
 focated in attempting it;  was still quite sensible when roused,
 and  complained of violent headach.   She now sunk gradual-
 ly, and died on the 22d;  she had continued sensible when
 roused, arid knew those about her till an hour before her death.
 She  had also  retained the sense of sight,  though the pupils
 were much dilated.
   Inspection.—The surface of the brain was natural; the sub-
 stance showed marks  of increased vascularity,  and the ven-
 tricles  were distended with colourless  fluid.  The left lobe of
 the cerebellum was entirely converted into a bag of purulent
 matter, of a greenish colour  and intolerable fetor.  It was
 contained in a soft and organized sac, which appeared to be
 of recent formation. A portion of the dura mater on the outer
 side  of the abscess was thickened and spungy ;  the  bone was
 sound ; the caput coli, and about eighteen inches of the extre-
 mity of the ileum, were of a dark livid  colour, but sound in
 their structure.

   Another case of abscess of the cerebellum has been describ-
 ed under a former article.—See Case III.


   § XIV.—Ulceration of the surface of the  brain.

   This appearance is uncommon, but it is distinctly describ-
 ed by several writers. A man, mentioned by Dr. Scoutetten, had
violent headach, followed by great disturbance of the stomach
 and  prostration  of strength.   He  was  relieved by topical
 bleedings, &c. ;  but, after  a week, the symptoms increased,
with  fever, and the pain was so violent as to produce scream-
ing.   In this manner  he went  on without relief,  and died on
 the twenty-sixth  day,—no  other symptoms being mentioned,
excepting  that he lay  with his eyelids  closed,  and his  fore
arms bent. On the lower part of the anterior lobe of the right
hemisphere of the brain, there was a superficial ulcer measur-
ing 13 lines by 7.  It was of a yellowish appearance, and its 
review of the  subject.
87
edges were unequal and ragged.   The dura mater and the pia
mater covering the spot were destroyed by erosion, and the pia
mater was in some other places inflamed ;  the brain in other re-
spects was healthy.   A similar appearance on the posterior
part of the brain was observed in a man who died of protract-
ed intestinal disease ; he had been affected for three days be-
fore his death with oedema of the forehead and left eyelid,
headach, delirium, and convulsive motions of the upper extre-
mities.*  The same appearance  in the cerebellum is mention-
ed by Mr. Howship.f  A soldier  at  Gibraltar  lay down and
fell asleep in the sun in a very hot day; he soon awoke in
great pain, and was confined to  bed for six weeks, with con-
stant and violent pain  in the forehead.   He then returned to
his duty, and was not heard of for six months, when he went
into the hospital again, affected with pain in the forehead. It
now became remittent, generally returning every morning, but
sometimes missing a day, or varying in the hour of attack;
there was no fever.   Two months after his  admission he be-
came suddenly delirious in the night, and soon  after expired.
On dissection, there appeared a  general increased vascularity
of the brain, without any decided disease, until the tentorium
was raised, when there appeared upon the upper surface of the
cerebellum an ulcerated superficial excavation, the  size  of a
shilling, containing a thin ichorous matter.  The pia mater at
this place was destroyed, and the dura mater was discoloured.
Dr. Bright has also given two examples of defined ulceration
of the surface of the brain, with loss  of substance.   In one of
them the symptoms were very obscure.   In  the other, the af-
fection followed an injury of the  pericranium, and was fatal af-
ter several weeks.
  The cases described under Section V.  appear to illustrate
the principal phenomena connected with inflammation of the
substance of the hemispheres.   In Case XXIII. we see it in
its recent state on the surface of the brain, and in Case XXIV.
we find it in the substance  forming a distinctly defined por-
tion in a state of active inflammation.  In  Case XXVII. we

 * Arch Gen. de Med. January, 1825.    t Med. and Phys. Journal, March, 1810. 
88        inflammation of the hemispheres.

see an inflamed portion of this kind passing gradually into
ramollissement;  and in Case XXVIII.  we see the ramollisse-
ment in a more advanced state.   In the subsequent cases, we
see more complete ramollisement, both uncombined and mixed
with purulent matter.  We then find the inflammation passing
into a distinct and encysted abscess; and finally we observe
it  terminating by ulceration of the surface of the brain.  Of
the cause of these varieties of termination we at present know
very little.  I have  thrown out a conjecture that the  ramol-
lisement occurs  chiefly in the  white matter,  and suppuration
in the gray; but it is mere conjecture.   That the ramollisse-
ment, however, is a result  of inflammation, I think the appear-
ances described in some of these cases place  beyond a doubt.
I have already stated my  belief that it also arises from another
cause, namely, disease of the arterial system, being thus ana-
logous to gangrene in other parts of the body,  which  we see
arising from these two very opposite causes.  In this manner
I have proposed to reconcile the  diversities of opinion which
at present exist among pathologists in  regard to this appear-
ance. In the symptoms which accompany inflammation of the
substance of  the hemispheres,  there appears to be such a di-
versity as must prevent us at present from attempting any ge-
neral statement of them.    The most common  appear to be
headach followed by convulsion,   either of one limb, or of a
more general  kind ; or a  sudden attack of convulsion, without
previous complaint of pain, the convulsed parts afterwards be-
coming paralytic. But in Case XXIV. no paralysis was observ-
ed after three days  of the most frightful convulsion ; while in
Case XXVIII. paralysis  was the first symptom,  and convul-
sion took place at a subsequent period.  In other cases, again,
we find paralysis of one  side of the body  and convulsion of
the other.
  On this interesting subject,  however, we  have not at pre-
sent a sufficient collection of facts to enable  us to  advance to
any general statement in  regard to the  symptoms, or to refer
particular symptoms to the particular seats or terminations of
the disease.  But there are numerous .facts of very great in-
terest which deserve  to be  recorded, without attempting any
thing farther than a  simple  statement of them in connexion
with the principal morbid appearances.  They refer chiefly to
the affection in the  various conditions of simple inflammation
ramollisement, suppuration, and ulceration ; and to some inte- 
REVIEW OF THE SUBJECT.
89
 resting phenomena  connected with the disease  in  a chronic
 form.
   I. In the state of  Simple Inflammation,  the affection
 seems in general to  be characterized by headach and convul-
 sion ; but in a more chronic form of it, as in Cases XXV. and
 XXVI., we see it productive of paralysis, without convulsion,
 and fatal in a state of simple inflammation, with all the symp-
 toms of perfect apoplexy. On the other hand, in Case XXVIII.
 the  palsy preceded  the convulsion.   In some  of  the cases
 which terminated by the encysted abscess, there is  reason to
 believe that the inflammatory stage was characterized by con-
 vulsion of  one or more limbs, followed  by temporary para-
 lysis, and that the permanent paralysis, took place  when the
 disease passed into suppuration.   In some of the other cases,
 again, it  seems probable  that the  inflammatory state  was
 productive of an attack of palsy, exactly resembling the ordi-
 nary hemiplegia from other causes.  This probably took place
 in the very interesting case, (No. XXXII.)  Of the disease in
 its more chronic form,  an  important  example  is related by
 Dr.  Treutler.*  A  woman aged 30, had been ill for  two
 months with  dropsy, which had  followed intermittent fever,
 and was connected with disease in the spleen.   In  the third
 month of her illness, she complained of a feeling of weight in
 the occiput towards the right side, with dimness of sight,  and
 a great propensity to sleep.   Her hearing became obtuse, her
 speech was  very indistinct, and her memory was lost.   She
 at last seemed to lose the power of every voluntary muscle, so
 that  she could neither move her legs nor arms, nor raise  her
 head.  Finally, she had convulsions and apoplectic attacks,
 and died suddenly about the end of the third month of her ill-
 ness, that is, less than a month from the commencement of the
 symptoms in the head.   In the posterior lobe of the right he-
 misphere of the brain, behind the  lateral  ventricle, a portion,
 the size of a large walnut, (fructus regise juglandis,) was  in a
 state of high  inflammation; the membranes adhered to  the
 surface of the brain in several places ;  where this did not  oc-
cur, there  was serous effusion under the arachnoid.  There
 was  no fluid in the  ventricles ;  there  were hydatids in  the
choroid plexus, which were most numerous on the right side.
The  spleen was  much enlarged; and  extravasated  blood, to
the amount of several pounds, was found in the abdomen ; it

      ' Treutlen  Auctariuin ad Helminthologiam Humani Corporai, p. I
                           12 
90
INFLAMMATION  OF THE HEMISPHERES.
was contained partly in the cavity of the omentum, partly be-
tween the laminae of the mesocolon, and partly under the  pe-
ritonseal coat of the descending colon.

  II.  The Ramollissement of the  cerebral substance
does not appear to be characterized by any uniformity of symp-
toms.  In particular, there does not appear to be any founda-
tion for a statement made by some of the French writers, that
it is distinguished by tonic contraction of one or  more limbs.
This symptom occurred in Case XXX. at an early period, and
afterwards  disappeared.  It is  also met with in connexion
with affections of the membranes, without any disease of the
cerebral substance ; and with the encysted abscess ;  and it is
frequently observed in cases of typhus, where there is  much
cerebral disturbance, but which terminate favourably.  Lalle-
mand* remarks, that he had taken  up the idea of the rigid con-
traction of the limbs being diagnostic of ramollissement, and
was very much perplexed when he met with a case  in which
all the limbs were in a state of the most remarkable relaxation.
  The cases which terminate by ramollissement seem in  ge-
neral to be characterized by convulsion, more or less extensive,
followed by paralysis and coma,  the convulsion ceasing for
some time before death, and  being succeeded by the  coma;
but in Case XXX.  the convulsion  continued with the utmost
violence till the very time of death.  In Case XXXIV., on the
other hand, there was no convulsion, but a sudden attack of
palsy, exactly resembling the ordinary attack of hemiplegia
from other causes.   In the very remarkable  Cases, XXXII.
and XXXIII., we  find ramollissement of very limited extent,
as the only morbid appearance, in connexion  with symptoms
of long standing; both cases being at last rapidly fatal  by a
sudden attack of convulsion.   In some of the subsequent cases,
again, we find most extensive destruction of the cerebral sub-
stance, without either paralysis or  convulsion, and even with-
out coma.  In one remarkable case  to be afterwards describ-
ed, namely, the last case under tubercular  disease, we shall
find destruction of the cerebral substance, to as great an extent
perhaps as is upon record;  while  the patient went to bed in
the state of health in which she had been for many months be-
fore her death, and was found dead on the morning.
  We find the same difficulty in attempting to ascertain  the

              * Lallemand, Recherches sur l'Encephale. 
review of the subject.
91
effect of ramollissement of particular parts of the brain, in pro-
ducing symptoms in particular organs.   Convulsion on the
same side with the disease, and paralysis  on the opposite side,
appear to be frequent symptoms, but, as  we have seen, by no
means uniform.  In several of the cases, the speech was  re-
markably affected, but they present no uniformity in the  seat
of the  disease.   The recovery of speech in Case XXXIII.,
was  a remarkable  occurrence.   In a case by Lallemand, in
which the upper part of both hemispheres was affected, there
was  resolution of all the limbs ;  and in one in which the  ra-
mollissement was  seated  in the tuber  annulare, there was
squinting, with resolution of all the limbs, and distortion of the
head backwards.  The same  writer describes two  cases in
which the disease was in the cerebellum.  In the one, there
were headach, phrensy, convulsive motions, and sudden death;
in the other, in which it was  in the left  lobe, there was loss
of speech, with palsy of the right side, and stupor ; it was fa-
tal in eight days.

  III.  In  the cases  which terminate by Suppuration, we
find  the same diversity of symptoms  as in the cases  now re-
ferred to.   The  suppuration, we have seen, varies, by being
in some cases confined in a distinct encysted abscess, and in
others forming an undefined mass of disease, in which puru-
lent  matter is more or less mixed with cerebral substance in  a
state of ramollissement.  In the latter form of the disease, the
symptoms are often exceedingly obscure  and undefined, as we
see in Cases XXXVI. and XXXVII.  In the encysted abscess,
they appear to be in general more marked and  severe.  The
course of symptoms in  Case XXXIX. was very remarkable.
The sudden attack of convulsion, followed by paralysis of one
arm, probably occurred in the  inflammatory stage, for when
the  symptoms  were relieved by the bloodletting  and other
remedies, the  arm recovered its motion.   The convulsion re-
turned, and the paralysis  along with it,  and again subsided;
and after several attacks  of the same kind, the  paralysis be-
came permanent.  The thigh and leg then went through the
same course.   In such a case, it appears highly probable, that
the  convulsion occurs  while  the  inflammatory state is going
on,  and that the period of suppuration is indicated by the per-
 manent paralysis.  In this case, three abscesses were met
 with ; but, whether the successive formation of these had any
relation to the successive attacks of the disease in the arm and 
92        inflammation of the hemispheres.

leg, must be matter of conjecture.  In a similar  ease, related
by Bartholinus, the leg was first affected, and  afterwards the
arm.   One abscess only is mentioned, of which it is merely
stated that it was on the opposite side.  In a case  by Schen-
kius, there occurred paralysis of the left side, and convulsion
of the right; there was a superficial abscess on the right side
of the brain.   Something similar to this occurred in a case to
be afterwards mentioned, (Diseases of Bones,) in which there
was paralysis of the left side, with convulsive agitation of the
right arm.  In a girl aged 5, whose case is described by Dr.
Bateman,* an  abscess was found in the posterior part of the
right hemisphere, inclosed in a  fine vascular sac, and contain-
ing four ounces of pus.   She was  first affected with  convul-
sion of the whole body, which continued for nearly two days;
i luring this time, the left side was in a state of rigid extension,
and the right was in constant motion ; and when  the attack
subsided, the  left side  remained  paralytic.   She then had
headach, squinting, blindness, and repeated convulsion; and
died after an illness of fifteen weeks, having been  comatose
for  only one day before death.   In some cases  of this  kind,
paralysis has occurred without convulsion, and in others, con-
vulsion without paralysis ; but one or other of these affections
appears to be  a common attendant on the encysted  abscess.
In a case described by Morgagni, the  prominent symptoms
were, pain of the left side of the head,  delirium, loss of speech,
and weakness of the muscles of the left side of the neck; the
man died in  14  days, gradually exhausted ; and an  abscess
was found in the right corpus striatum, which had burst into
the ventricle.   In  a case by Valsalva,  in  which the disease
was in the corpus striatum, the speech  was much  affected,
and one side was paralytic.  In another, there were indistinct-
ness of speech, and paralysis of the right side, connected with
an ulcerated cavity at the base of the brain on the left  side.
In a third case by the same writer, there were paralysis of the
right side, and convulsion of the left, with an ulcerated cavity
in the  substance of the brain under the choroid plexus of the
left side.  Many other varieties occur in the symptoms,  in re-
gard to which it is unnecessary to enter into any lengthened de-
tail.   In a case by Lallemand there were cramps of the limbs
followed by a  sudden attack of palsy of the right side.   After-
three days the  affected  limbs were seized  with  convulsions
* Edir*. Med. Journal, vol. i. p. 150. 
review of  the  subject.
93
which occurred for several days, and ended in fatal coma.  Ano-
ther case, by the  same writer, began with pain in the  right
side of the head and tremor of the left arm.  This was follow-
ed by a continued convulsive flexion and extension of the left
arm, which after some  days passed into palsy.  There  were
then some convulsive motions of the limbs of the right  side ;
the abscess was in the right side of the brain.   In a man, men-
tioned by Broussais, an extensive abscess was  found in the
centre of each hemisphere, without any other symptom than a
puculiar dulness of manner, with taciturnity, and at last  coma
after 37 days.   In cases of a more chronic kind, the  abscess
is often found inclosed  in a mass of tubercular matter or  indu-
rated cerebral  substance.  These have probably supervened
upon chronic disease of the brain, which, after continuing long
in an indolent state, has at length passed into suppuration.
In a few cases, abscess has been found in the brain  without
any symptoms which indicated its existence.  Morgagni found
one in the posterior part of the brain  in a man who  died  of
gangrene of the nates,  without any symptom in the head.   A
man, mentioned by Dr. Powel, was received into St. Bartholo-
mew's hospital on acount of cough, dyspnoea and  bloody ex-
pectoration.   He died  after he had been a month in the hos-
pital, having been for some time before his death in a dozing
state, with occasional delirium,  but without coma, and he had
never complained of his head.  His lungs Were much diseas-
ed, and an abscess the size of a large walnut was found in the
substance of the brain, under the anterior part of the corpus
callosum.*
  In the encysted abscess of the cerebellum, the symptoms
seem to be less violent than when the disease  is in the brain.
A very slight convulsion occurred once  in  Case III.   In
CAse XLV.  the most remarkable symptom was the loss of the
power of swallowing.   In a case by Plancus, there was pa-
ralysis  of one side, and it is stated to have been on the  same
side with the disease.f   In Case III., though the disease was
in the cerebellum, the principal  seat of pain was in the fore-
head, and this has been observed in other cases of the same
kind.
  IV.  The  superficial  ulceration of the  brain ap-
pears to be a rare occurrence, and some of the cases of it pre-
sent phenomena of rather an interesting  character.   A man,
* Med. Trans.Coll. of Phys. London, vol. y.
t Storia Med. d'una Postema del lobo destro del cervelletto. 
94        INFLAMMATION OF THE HEMISPHERES.

mentioned by Dr. Powel,* was affected with a convulsive mo-
tion of the left side of his body, which very much  resembled
chorea ; he was free from it  during sleep, and  had no other
complaint.   This  affection  continued five weeks, and then
suddenly terminated in palsy of the affected side.  Soon af-
ter this, his right hand and arm became  convulsed, but in  a
slighter degree ; he then became gradually comatose, and died
two months after the commencement of the complaint.  On
the anterior part of the  right hemisphere of the brain, there
was a superficial loss of substance from ulceration,  two inches
in length and as much in  breadth ;  it presented an irregular
excavated appearance, and a thin layer of curdled  matter was
deposited in it.  There was a similar disease, but  much less
extensive, on  the  anterior part of the  left hemisphere, and
there was much fluid in the ventricles.  A lady, mentionedby
Dr. Thomas Anderson! of Leith, had been for several years
liable to headach, Which was most violent at the crown of the
head.   After she had suffered for a considerable  time from this
pain, she was seized with a convulsive affection of the left arm
and leg.  It occurred in paroxysms, attacked her several times
every day, and generally continued about half an hour at each
time.   This complaint became  gradually more  and more se-
vere ; the right side became slightly affected in the same man-
ner, and she was afterwards liable to attacks of coma, in which
she often lay for 24 hours at a time.   She died at last of gra-
dual exhaustion.   On the upper part of the right hemisphere
of the brain, there was a superficial loss of substance from ul-
ceration, two and a half inches long, one and a half broad, and
nearly an inch in depth.   In the bottom of it there  were found
some thin laminae of a firm brownish matter, with  stony con-
cretions, some of which broke into sand on the slightest touch.
   The  effect  of superficial  inflammation of the brain, or its
membranes, is well illustrated by another case related by Dr.
Anderson, in which the disease took place under his eye.   A
boy suffered, from an injury of the head, the depression of a
considerable portion of the right parietal bone, the depressed
portion being  forced through the  dura mater, and driven in-
wards  upon the brain.   He had paralysis of the left side  and
the left eye was insensible.   The depressed portion being re-
moved, the paralysis was greatly diminished,  and the eye re-
covered a considerable  degree  of vLion.   On  the third day
* Trans. Coll. Phys. London, vol. v.   \ Trans. Roy. 
REVIEW OF THE SUBJECT.
95
after the operation, the wound in the dura mater was inflamed,
with considerable tumefaction; and immediately the left leg
and arm became paralysed, the paralysis being accompanied
by convulsion;  and the left eye also became again insensible.
He had frequent convulsion of  these parts for several  days,
the right side not being in the least affected, when, suppura-
tion having taken place, all the symptoms subsided.   Had the
disease occurred without such  an  outlet as  was in this case
afforded to the matter, the suppuration, instead of relieving
the symptoms, would probably have induced permanent para-
lysis and fatal coma.  A man, mentioned by Mr. John Bell,
suffered, from an injury of the head, extensive  extravasation
of blood on the surface of the brain, which was removed by
repeated applications of the trephine.   During the cure, which
occupied three months, the left side of the brain suppurated
five or six times.   The attack of inflammation was always ac-
companied by fever, stupor, and difficult deglutition ;  but these
symptoms were removed by the suppuration.   These attacks
occurred at various parts of the brain.  When they were to-
wards the anterior part, he had double vision, which also was
removed by the suppuration;  when they were  towards the
posterior part, there was not double vision, but a state of vi-
sion  in which a candle was seen with a halo around it.
   Ulceration of the surface of the brain I have  seen only in
one  instance, in a preparation which was shown me by Dr.
Macintosh.   There were on various parts of the surface of the
left hemisphere, spaces of superficial ulceration of various ex-
tent, with ragged edges, and sensible loss of substance.  The
affection occurred in a child of 18 months, and was complicat-
ed with effusion in the ventricles, and ramollissement.   The
pia mater  and the arachnoid were destroyed at the  ulcerated
spots; and the pia mater  in other places was studded with
minute tubercles.  The symptoms were not to be distinguish-
ed from those of hydrocephalus in its ordinary form.  There
were also  numerous granular tubercles in the lungs,

   V.  THE  INFLAMMATION OF THE  -CEREBRAL  SUBSTANCE
occurs in a  chronic form,  in which the symptoms may
continue for months, and the disease then prove fatal by sup-
puration, or without having suppurated. In Cases XXVII. and
XXVIII. we have remarkable examples of this form of the dis-
ease proving fatal without suppuration.  In Case XXVII. we
can  have little doubt that  the  disease had existed in the first 
96        INFLAMMATION OF THE HEMISPHERES.
attack, and, after a protracted illness, had been removed or in
a great measure subdued.   It then took place again, and was
fatal with loss of speech, palsy, and coma; yet after all, it had
not advanced beyond the state of simple inflammation.   The
progress of this more chronic form of the disease seems to dif-
fer considerably from the other modifications of it.   We have
seen that it may continue for a considerable time in a state of
simple inflammation, and  in that state  may be fatal with all
the symptoms of perfect apoplexy.   It may also, after conti-
nuing for some time in this state, pass  into ramollissement or
suppuration ; but it appeares, that in some cases  it terminates
by induration of the part of the brain which has been the seat
of it.  A degree of this  occurred in Dr. Hay's case, and it
appears probable that,  as the induration advances, the  in-
flammatory appearance  subsides; the part is  then left in a
state of simple induration, and at a more advanced period may
pass into unhealthy suppuration.   This  state of disease may
either affect a considerable portion of the brain, from the sur-
face downwards, or may be confined to a small circumscribed
portion in the substance of the hemisphere.  In this case, the
affected portion appears, in some instances, to be afterwards sur-
rounded by a cyst, and this appearance has been called a tumour
in the brain.  It is probable that it is merely a part of the cere-
bral substance in a state of low scrofulous  inflammation; that
in its early stage, it  is  a  disease which may be  cured; and
that the formation  around it of a  cyst of coagulable lymph, or
its termination by induration of the  part, are the points in its
progress which give  it  the character  of organic or hopeless
disease.  In  either of these states it may be fatal after pro-
tracted symptoms, or it may terminate by suppuration.   This
affection, in its first stage, was  observed  by Burserius in the
anterior part of the right hemisphere, in  a man who  died after
an illness of four months;  he had been affected with constant
pain of the head  near  the vertex, fever, paralysis of the  left
side, and convulsive affections which  occurred  at intervals.
Fantonus  found a similar  disease in the corpus callosum, in
a man who had been long affected with epileptic paroxysms,
and at last died comatose  and convulsed.  In the state of
suppuration, Burserius  found one the size of a pigeon's egg
in the outer part of the right hemisphere under the squamous
suture, in a man who had been  affected for several months
with intense  headach,  and convulsive tremors of the whole
body, which were most severe on the left side.   He  found 
Review 6f fliE subject.
97
artdther in the posterior part of trie brdiff near the tefitoriurh,
in a wdnfialfi who h'ald been ill for  several months #ith severe
headach without fever:  the" pain was so hrterise as almost en-
tirely td deprive her 6f sleep, and she seems to  have been
gradually worn out by the severity of it without any other fe-
markaMfe symptom1.
   This form of  chronic ir/ffarrirrfatiori of  a small  part  of the
brain1 is? a! disease of much interest.   The symptoms may go
on for several months, so as to assume the Character of organic
disease; they maty remit,' so as to  resemble periodical head-
ach; the  disease may be fatal with symptoms  resembling
apoplexy;  6r it may pass into permanent induration  of the
part afFected; of, after it has appeared to resist all our reme-
dies, it may gradually subside.  This1 agrees exactly with the
course o'f chrbnie  or scrofulous inflammation, as we observe
it  in external parts.   We see it in the eye, iri the lymphatic
glands, in th£ testicle-, in the mamma, and in the cellular tex-
ture.   It .takes  place rapidly, producing enlargement of the
parts,1 and derangement of the functions;  it may continue sta-
tionary for  a Considerable time ; it may trieri terminate  by un-
healthy suppuration  or" ulceratioriy or by permanent induration
of the part; or,  after resisting for a long time all our remedies,
it may gradually subside,with'oiit leaving any permanent chiange
in the organization of the part.   I think there is  little doubt
that something  of this  kind takes place in the'brain, and if
thte doctrine be  admitted', the practical  application 6f it will
be, that we shall be  less disposed than we usually are, to  con-
sider such cases as depending upon organic disease, and  con-
sequently not the objects of active  treatment.
   The' progress  of this  interesting affection' is well illustrated
by Case XXVH., and there are others on record which show
it  under some varieties in the symptoms.   A gentleiriari, men-
tioned by Dr. Powell, was affected with severe headach, which
occurred in paroxysms': during the paroxysms,' which often
cbrttiriued for several hburs', he had double vision, mental de-
pression,' and at one time muscular tWitehes arid riiimbness of
the l?ft sid&   The rjiilse was variable',  being  sometimes &
little frequent, and' sometimes rather below' the natural stand-
ard.  By large  and  repeat&d bloodletting, &c., he was'much
relieved, but, after a short interval of relief, the complaint re-
turned with £reat violence, arid his vision remained perma-
nently dotible.   After several aggravatioriS arid remissions or
this kitidt Hi* had, at the' erid  of three weeks, an interval of
                            13 
98        INFLAMMATION  OF THE HEMISPHERES.

ease for more than a fortnight.  The pain then returned with
violence, and was accompanied with spasmodic  affections of
the muscles of the neck.   He then derived temporary relief
from narcotics, and,  soon after this, the complaint assumed so
much of a periodical character that it was treated by bark;
the pulse at this  time was natural.  Under this treatment the
paroxysms became rather less severe, but not less frequent;
and they were attended occasionally by convulsive  motions,
which chiefly affected the right side.   The paroxysms occur-
red at very uncertain intervals.  They sometimes consisted of
pain only, and sometimes of pain accompanied by the convul-
sive motions.  He died suddenly  in a convulsive attack, two
months after the commencement of the complaint;  for some
time he had been considered as better, and had sat up for two
hours on the day preceding the night on which he died.  The
anterior part of the right hemisphere was found much changed
in its structure and indurated, so  that it is described  as a tu-
mour.   When the dura mater was first removed, the part thus
affected appeared to rise higher than the neighbouring parts,
and the cerebral  substance surrounding it was very soft.  The
morbid condition here described is probably a different stage
of the disease which-occurred in Cases XXVII. and XXVIII.;
and there was a considerable similarity in the  symptoms to
the  first attack in Case XXVII.
  The affection  may likewise pass into a still  more chronic
state of induration, in which it may be protracted for a greater
length of time, but producing urgent symptoms; and  may at
last be  fatal by  suppuration, or without having  suppurated;
or,  if it be seated in the superficial parts of the brain, it may
terminate by the ulceration of the  surface formerly referred to.
A man, mentioned by Dr. Anderson, received a violent blow
on the back of his head, from the boom of a  ship, which fell
upon him as he was  stooping under it.  After  sometime he
had pain  in the part, which became  gradually more  severe,
and, after 18 months, brought on convulsive paroxysms of both
upper and lower  extremities, the violence of which put  an end
to his life, after he had suffered from them  for  several months.
Both  hemispheres of the brain at the posterior part were found
inflamed and much hardened.   The diseased parts  adhered
closely to the dura mater, and to the falx ;  and the dura  ma-
ter  at that part was thickened and indurated.   A man aged
45,  mentioned by the same writer, had been liable for several
years to convulsive paroxysms resembling epilepsy,  but with 
REVIEW OF  THE  SUBJECT.
99
this peculiarity, that the convulsion was confined to the right
arm  and leg.   The  attacks occurred  at irregular intervals,
generally once in three or four weeks, and were succeeded by
stupor which continued about half an hour.   Without  any
change in the complaint he Was killed by an injury of the head.
A portion of the left hemisphere of the brain was found indu-
rated, and  closely  adhering  to the  dura mater, which at  that
place was much thickened and  hardened.  Extravasated blood
was found in another part of the head, which appeared to have
been the effect of the injury, and the immediate cause of death.
In a man aged 35, who had suffered for several months from
violent pain in the forehead with  epileptic paroxysms, Mor-
gagni  found the anterior part  of the right hemisphere  of the
brain indurated, and adhering to the dura mater.  Baader re-
lates the case  of a man aged  40, who became  suddenly  epi-
leptic, with pain at a particular part of the left side of the head.
There was extensive sensibility of the surface of the left hand
and  arm, so that  the  slightest breath of cold  air upon them
brought on convulsive  twitches.   After an illness of five years
he died rather suddenly.   At the part which had been the  seat
of pain, there was superficial  induration of a portion  of the
brain,  and under the indurated part there was an abscess the
size of an egg.
  From the imperfect view now given of this subject, I think it
will appear, that the inflammation of the cerebral substance is
an affection deserving accurate investigation.   There is every
reason to believe, that it exists in various degrees of activity;
that in the most active  form  it advances speedily to ramollisse-
ment or suppuration; but that it also exists in a chronic form,
in which its progress is very slow, so that it  may produce ur-
gent  symptoms for  a  considerable length of  time, without
having advanced beyond that  stage in which there is a chance
of recovery.   This latter form we have seen reason to believe
may afterwards pass into suppuration, or may terminate by in-
duration of the cerebral substance, and  may thus assume the
characters of  organic  disease.  The disease may affect any
part of the brain, and often  appears to commence in a  very
small portion of it, and to extend gradually over a larger  por-
tion.  It appears  to be in cases of this kind that we  chiefly
meet with some singular examples of gradual paralysis, be-
ginning perhaps in a very slight degree, or in a single muscle,
and advancing very gradually to more perfect and more ex-
tensive palsy.   A  small part of the brain in such cases  is pro- 
100       INFLAMMATION OF THE HEMISPHERES.

bably undergoing this low  state of inflammation, gradually
gaining ground, and at length^ terminating either by fatal coma
or permanent paralysis.
  In the'palsy conneqted with these inflammatory aflections,
there is sometimes, especially in the early stages, violent pain
in the affected limbs.  In some cases, again, the loss of power
is accompanied by total loss, of feeling ; in  others,  the feeljng
remains entire ; and some remarkable examples, are met wifli,
in which,  the feeling  is morbidly increased,.   A) case of thi,s
kind has been already referred to ; another is  menti,p4?ed ty
Lallemand.   In this case  there had been,' after a blow on the
head, headach, impaired intellect, and weakness of the limbs.
Six weeks after, there was a sudden attack of, loss, of speech,
with palsy of the right sjde, and increased sensibility of the
parts, so that a touch was painful.  Ten days after this, there
was an attack of palsy of the left side, with fatal coma. There
was an appearance of inflammation and extensive ramollisse-
ment of*  the cerebral  substance  of the left side, and  on the
right  side, extravasation of blood, which had' obviously been
the origin of the, fatal attack.
  The disease occurs in the cerebellum in  tb^e same chro-
nic form which has  now been  referred,  to in  regard to the
brain ; it in some cases exhibits nearly the same symptoms,
and in others the symptoms are extremely obscure.   A man,
mentioned by Mr. Douglas, had been for three months affect-
ed with pain in the forehead, which  generally obliged, him to
sit with his head  leaning forward ;. he  had bad appetite and
disturbed sleep, but no other symptom.  He died  suddenly in
an attack resembling  syncope,  haying been  for a day much
better, with good appetite and  quiet sleep.  An encysted ab-
scess was found in the middle of the cerebellum,  and a rup-
ture of the left lateral sinus, which probably was the immedi-
ate cause of death'*   A man,  mentioned by Serres,t after  a
blow on the back and lateral part of the head, which  stunned
him at the time, had  certain unsteadiness  in walking, which
made him always anxious to take the arm of a friend ; and he
had a delicacy of his  head, which made him much affected by
a small  quantity of  wine.  This continued about  eighteen
months, when he became sad  and irritable, with trembling of
the limbs. Soon after, the left leg became paralytic, and the arm
* Edjn. Med. Ess. and Obser. vol. vi.
t Recherches sur Le Cervelet.—Journal de Phys-iologie, 1822—23. 
         INFLAMMATION OF  THE  OENfRAL PARTS.     101

of the same side was numb and weakened.   After the inser-
tion of a seton in  the neck,  the arm recovered, and, three
months after this, t^e patient  died with fever, delirium, and an
affection of the bowels.   There was disease in the right lobe
of the cerebellum, with an abscess and extensive softening,—
In another  man, mentioned, by the same writer, who died in
fprty days,  there was palsy of the right leg  with wasting of
the limb, but without loss of sensi^jlity, the arm being little if
at all affected.  There was ramollisement of the  left lobe of
the cerebellum, occupying  chiefly the centre of the left  pe-
duncle.
                      SECTION VI.

INFLAMMATION  0# THE CENTRAL PARTJS OF THE  B.RA.IN,--
   THE  CORPUS  CALLOSUM,  SEPTUM  LUCIDUM, FORNIX, AND
   THE  MEMBRANE LININ^  THE VENTRICLES.

   The morbid  conditions which, I  mean to consider under
this head,  embrace the various  forms of disease which have
usually been included under the term acute hydrocephalus.  Jn
venturing to refer; them, to, a place in the general arrangement
of the inflammatory affections of the brain, I may perhaps be
considered as advancing too rapidly to a conclusion in regard
to the pathology of this important class of diseases.  But from
all that I have observed of the affections themselves, andftpm
the analogy of the corresponding diseases  in other parte of
the brain, I have now very little  hesitation in arranging them
in this manlier.  I  shall state the grounds which have induced
me to take this view of the subject, and, confining myself in a
great measure to a faithful relation of facts,  shall merely pro-
pose the inquiry as one of much interest  for farther observa-
tion.
  The  disease  seems  to  present itself under two  different
forms.   In the one, the inflammation, appears to be seated in
the membrane lining the ventricles ; in the other, in the white
matter forming the fornix, septum lucidnm, and corpus callo-
sum.   In the former case, we find, the ventricles filled with a
turbid or milky fluid, sometimes containing shreds of coagula- 
102      INFLAMMATION OF THE  CENTRAL PARTS.

ble lymph, and  sometimes  having entirely the characters of
purulent matter.   These appearances are often combined with
a deposition of flocculent matter  or false membrane on  the
surface of the choroid plexus, or on the inner surface of  the
membrane lining the ventricles, and sometimes with ramollis-
sement of the cerebral matter immediately surrounding them.
In the latter case,  the affection presents itself in the form of
ramollissement or  white  pulpy degeneration  of the  parts af-
fected.  The septum lucidum is found perforated by a ragged,
irregular opening, from the softened portion having fallen out.
The fornix has lost its consistence in the same manner ;  and
either has lost its figure, by having fallen down into a soft, ir-
regular, pulpy mass,  or,  retaining in some degree its figure,
while it is not disturbed, falls asunder when the  most gentle
attempt is made to raise it.  The lower part of the corpus cal-
losum is often affected, though, I think,  more rarely than the
other parts ; and there is frequently a similar degeneration of
the cerebral matter immediately surrounding the ventricles.—
It is generally, but not always accompanied by effusion in the
ventricles of limpid fluid.  The substance which is the  pro-
duct of the disease, is of a pure white  colour, without fetor,
and without the slightest resemblance to purulent matter.  It
sometimes shows  a slightly fibrous texture, but in general is
entirely of a soft  pulpy consistence without any cohesion of
parts.
   From all that I  have observed of this affection, I have no
hesitation in considering it as the termination of inflammation
in these particular parts.   It is an  appearance of very frequent
occurrence, and seems to hold an important place in the pa-
thology of the brain, and  particularly  in the pathology of
acute hydrocephalus.  A most interesting point in the history
of it is, that it may be fatal without effusion, and  without  any
other morbid appearance, though with all the symptoms which
are usually considered as indicating  acute hydrocephalus.—
The first case of it which I shall  present seems  to  establish
the inflammatory origin of the affection, by showing the per-
foration of the septum lucidum, surrounded by a ring of in-
flammation ; I shall then show it as the only  morbid appear-
ance in cases which were fatal  with the usual symptoms of
acute disease  in the brain ; and finally,  shall submit a selec-
rion of cases,  showing its connection with serous effusion in
the various forms of acute hydrocephalus.   In regard to  the
pathology of this  affection,  I may also  refer to the facts  for- 
         INFLAMMATION OF THE  CENTRAL PARTS.     103

naerly adduced  with respect  to the ramollissement  in other
parts of the brain.  Some of them seem to furnish the most sa-
tisfactory evidence of the inflammatory origin of this appear-
ance, by enabling us to trace, in the same mass, one part in a
state of inflammation, and  another in a state of ramollisement,
and the one distinctly passing into the other.
   I shall begin this part of the subject by an example of an
affection, which seems  to  be rare,—inflammation confined to
the membrane lining the ventricles.


§ I.—Inflammation of  the  membrane lining the  ven-
                        tricles.

   Case XLVI.—A child  aged 10 months, (January, 1819,)
had fever, starting and  vomiting;  tongue white ; bowels ob-
stinate.  After  a week, the  symptoms abated ; his sleep be-
came calm, and he  was at times  playful; but the vomiting
continued, with frequent pulse.  In this  manner, he  continu-
ed without any  remarkable change in the symptoms for nine
or ten  days; he  then  became affected  with squinting and
blindness, and very rapid pulse, and the  vomiting continued;
he died three days after the occurrence of these  symptoms,
and death was preceded by a slight convulsion.
   Inspection.—The ventricles were distended with six ounces
of fluid, which was turbid, and contained in itflakes of yellow
coagulable lymph.  The  lining membrane of the ventricles
was  thickened, and was  easily separated by dissection: its
inner surface was covered  by a thick coating of soft, yellow,
adventitious membrane. The septum lucidum appeared to be
thickened, and the pineal gland was distended with a greenish
fluid.  On the posterior part of the cerebellum, the arachnoid,
to the extent of a crown piece, was thickened and covered by
adventitious membrane ; betwixt it and  the pia mater at this
place, there,was some deposition of puriform matter.
   A ease  considerably similar to this in the morbid appear-
ances,  is related  by Golis,* though the  progress was much
more rapid, and the symptoms were more violent.   A  child
aged 14 months, after a restless night, was seized with violent
fever and  general convulsion, which subsided after topical
bleeding, but sood returned with great violence, accompanied
* Golis on Hydrocephalus Acutus, Case II. 
104      INFLAMMATION OF THE CENTRAL PARTS.
by spinal cramps, hemiplegia^ blindness, dilated pupil,  and
distortion of the face ; he died the same night, about thirteen
hours after the attack.   The ventricles contained three bunces
of turbid fluid ; the inner surface of the ventricles and the sur-
face of the choroid plexus were cbvered by adventitious mem-
brane ;  and a similar deposition was found on the corpus cal-
losum, and on the convolutions' of the brain.   The same  ap-
pearance is mentioned by this author in several other cases.—
Inflammation must have existed in the same part  in a case
formerly described (Case XV.,) in which, along with exten-
sive meningitis, there was purulent matter filling the ventricles.
Morgagni describes a case in an adultj in which the left ven-
tricle was found full of purulent matter without any disease of
the cerebral substance.  The characters of this case were fe-
ver,  apoplectic symptoms, delirium, convulsions, and palsy of
the right side.  An interesting case is also mentioned by M.
Gendrin, in which both  lateral ventricles, and the third ven-
tricle, were distended with  turbid  fluid; their" lining  mem-
brane thickened',  and covered with  a thick  greenish-yellow
matter; and! the fourth ventricle Was full of pus.  The patient
was  a man 41 years  of  age, who, after complaining for five
days of headach,  lassitude, and impaired digestion, was seized
with fever, with increase of headach and  vomiting, followed
by drowsiness, delirium, rigidity of the neck  and  dilated pu-
pils, and he died eornatose in' six days'.


§ II.--THE INFLAMMATORY ORIGIN  OF  THE RAMOLLISSE-
             MENT OF THE SEPTUM  LUCIDUM.

   Case XLVII.—A girl aged 6,  about  two  months before
her death, had a violent and obstinate diarrhoea,  by which
she was much emaciated; after three or four weeks it abated
considerably, arid for a  fortnight  she was better.   She was
then seized with severe pain of the belly, vomiting and head-
ach, the bowels being rather obstinate.  The pain of the head
was violent, and bhiefly  referred tb the forehead.  The pulse
was from 30 to  40 in a minute, and there was a constant con-
vulsive motion of the right arm and leg.-  Without any re-
markable change  in  the symptoms, she sunk  gradually into
stupor, and* died after two days of perfect coma, about a fort-
night from the commencement of the headach.  The convul-
sive motion of the right  arm and leg  continued through  the 
        RAMOLLISSEMENT OF THE  CENTRAL PARTS.    105

whole course of the disease, and almost to the moment  of
death.  The pulse continued from 30 to 40 in a minute until
a very few days before her death, when it rose to 70, and oc-
casionally to 80.
   Inspection.—The ventricles of the brain were  distended
with colourless fluid.  In the septum lucidum, there was a rag-
ged, irregular opening, from loss of substance, and the open-
ing was surrounded by  a  ring of inflammation.  The inner
surface of the  ventricles was in a state of high vascularity,
and the cerebral substance immediately bounding them, was
in some places considerably softened and broken down.  In
the anterior part of the left hemisphere, a portion of the brain
was dark-coloured and firmer than  natural, and  some small,
hard tubercles were imbedded in it.   The inner surface of the
caput coli and of  the ascending colon was of a dark-red co-
lour, and large patches were elevated into a dark-red fungus.


§  III.—Ramollissement of the  central  parts fatal
                   WITHOUT  EFFUSION.

   Case  XLVIII.—A woman aged 30, (18th June, 1816,)
was affected with violent pain in the head,  which extended
across from temple to  temple.  She  was extremely restless,
tossing from one side of the bed to  the other, owing to the
intensity of the pain;  eyes slightly suffused, and impatient of
light;  pupils contracted ; the pulse 60, soft and rather weak;
tongue white.   She was bled  repeatedly, both generally and
topically, and used purgatives, «old  applications to the head,
blistering, &c.   For three days she  appeared much relieved ;
the violent pain was  removed, and she complained of pain
only when  she moved  her head ; pulse from  80 to  90.   She
was quite  sensible, but considerably oppressed and inclined to
lie without being  disturbed.  On the 22d, her speech  was
affected ; she was sensible of it herself, and said that " she
felt a difficulty in  getting out her words ;" pulse  112.   (23d
and 24th)  Increasing stupor, and at times  incoherence, but,
when  roused,   she  answered questions  distinctly;  double
vision; made no  complaint, but said her head  was better.
Pulse from 112 to 120.  (25th)  Increasing  stupor.  (26th)
Complete  coma and dilated  pupil; pulse  108 and of good
strength;  died in the night.
   Inspection.—The fornix  and septum lucidum were broken
                            14 
106     RAMOLLISSEMENT OF  THE CENTRAL  PARTS,

down into a soft white pulpy mass.  There was  no effusion
in the  ventricles, and no  other disease in any  part of the
brain.

  Case XLIX.—A  man aged 36, a  blacksmith, had  been
for  some  months affepted with pectoral complaints, which
were considered  as  phthisical.  On the 10th of November,
1818, being suddenly told of the death of his daughter, who
died of phthisis, he instantly complained  of  headach ; and,
after another day or two, a remarkable change wa* observed
in his temper,  which became uncommonly fretful and irasci-
ble.   He still complained of  constant  headach, which  was
much increased by motion ; his pulse varied from 70 to 110.
In this state he continued for a week, without any alleviation
of the headach.   In the second week he began to be slightly
delirious, with a tendency to stupor, the headach continuing
very severe.  He became gradually more and more oppressed,
and at last comatose ;  and, after perfect coma of four days
continuance, died on the 27th.  His pectoral symptoms had
entirely subsided after the commencement  of  the complaints
in his head.  I did not see this patient during  his life, but
was present at the examination of the  body.
  Inspection.—The membranes of the brain were very  vas-
cular.   There was no effusion  in  the  ventricles, beyond the
usual quantity.   The septum lucidum was much broken down,
and a large opening was formed through the centre of it.  The
fornix was reduced to a soft white mass, which could not be
raised.  There was no other morbid appearance in any part
of the brain.  The lungs were extensively tubercular, and in
some places suppurated.
  The two cases now described are the  only examples which
have occurred to me, of the ramollissement of the septum and
fornix being fatal, without any other morbid appearance.  The
only cases in which I find it taken notice of by  other writers
are, one by Senn and one by Lallemand.  In the case by M.
Senn,* the patient was eleven years of  age.  After some days
of fever, with  pain of the belly and vomiting, she complained
of violent pain in the forehead, which  was constant and se-
vere for several  days ; and, after a day  or two,  was accom-
panied by dilated pupil, and distortion of the eyes upwards.
This was  followed by delirium and a spasmodic  retraction of
* Senn, Recherches sur la Meningile Aigue des Enfans, Case VIII. 
       WITH  EFFUSION OR  ACUTE  HYDROCEPHALUS.     107

 the head;  she died on the eighteenth day of the disease,
 without perfect coma.   The ventricles of the brain contained
 but a few drops of fluid.   There  was extensive  ramollisse-
 ment of  the  corpus  callosum, septum  lucidum,  and fornix,
 without any change of colour  in the parts.  The vessels  of
 the membranes were distended with blood ; there was no other
 morbid appearance in any part of the brain.  The patient of
 M. Lallemand* was a woman  of 40 years of age, who died
 after an ilbaess of about fourteen days ; the principal  symp-
 toms were^ fever with violent delirium,  and convulsive move-
 ments.   There was  extreme loquacity for some days, after-
 wards  somnolence and contraction  of the limbs, with extreme
 sinking.   The brain was found entirely  sound, with the ex-
 ception of the corpus callosum and fornix, which were trans-
 formed into a species of white pulp.


 §  IV.—Ramollissement  of  the central parts  com
   BINED WITH SEROUS EFFUSION, CONSTITUTING THE MOST
   COMMON FORM OF  ACUTE  HYDROCEPHALUS.

   Case  L.—A boy aged 12,  (August, 1818,) had been  for
 several weeks observed to be languid and declining in strength,
 with some cough and pain  in his breast.   A fortnight  before
 death,  he began to complain of his head,  and  was then first
 confined  to bed.   After a week, when he was first seen by a
 medical man, he still complained much of his head, was op-
 pressed,  and answered  questions  slowly  and heavily; had
 some diarrhoea and frequent pulse.   The oppression increased,
 and four  days before his death he  lost his  speech and the
power  of the right side.   This was followed by blindness and
perfect coma, and he died about the fourteenth day from the
commencement of the affection of the head, the pulse having
continued uniformly frequent through the whole course  of the
 disease.

   Inspection.—All the ventricles were distended  with  fluid ;
the septum and fornix were so completely broken down, that
the two lateral ventricles and  the  third ventricle  seemed to
form one  cavity; there was also an extensive ramollissement
of the  cerebral substance on the anterior part, so that the ca-
* M. Lallemand, Recherches sur l'Encephale, lorne i. p. 184. 
108     RAMOLLISSEMENT OF  THE  CENTRAL  PARTS.

vity thus formed by the ventricles extended  within  half an
inch of the anterior part of the brain.

  Case LI.—A boy aged 7, (October, 1818,) had fever, and
headach, which was referred chiefly to the back part of the
head;  and the bowels were obstinate.  After six or seven
days, the pulse  came  down  to  the natural standard.   The
headach continued without any remarkable symptom till a few
hours before his death, when he fell into a general  state of
tonic spasm of the whole body.  He died after continuing in
this state two  or three hours  about the 14th day of the  dis-
ease.   There had been in  this case no coma, but he had con-
tinued quite sensible till the attack of the convulsive affection.
  Inspection.—The ventricles were distended  with fluid, and
there was extensive ramollissement of the septum and fornix,
and of the cerebral matter immediately surrounding the ven-
tricles.

  Case LII.—A strong young man, aged 20, (18th Septem-
ber, 1814,) was affected with violent headach, extreme rest-
lessness and some  delirum ; face flushed ; pulse 60.   He had
been unwell so as to keep  the house for a week, but had been
only occasionally in bed;  the symptoms had  been much in-
creased for two days ;  pulse, on the former days, from 80 to 90.
Large and repeated bloodletting, and the other  usual reme-
dies, were employed with  activity.
  (19th and 20th) No improvement; violent headach, and a
good deal of delirium ; pulse from 75 to 80.
  (21st and 22d) Less delirium; pulse 80.
  (23d-and 24th)  Continued better; pulse from 80 to 84.
  (25th)  A tendency to  stupor; began not to know those
about him.
  (27th)  Perfect coma, in which he lay  for  four days, and
then died.  His pulse had continued from 75 to 84.
  Inspection.—Much fluid in the ventricles, and a good  deal
found in  the base of the skull.   The fornix  was broken down
into a shapeless mass  of white pulpy matter.   From similar
destruction a large opening had been formed  in  the  septum
lucidum, and there was also considerable softening of the ce-
rebral matter immediately  surrounding the lateral ventricles.
There  was a deposition of false membrane on the upper sur-
face of the cerebellum. 
ACUTE HYDROCEPHALUS.             109
  Case LIII.—A man  aged 21, (3d  Sept., 1816,) was af-
fected with violent headach, impatience of light, and frequent
vomiting; had an  oppressed look, with a fixed expression of
his eyes; pulse 70 and  strong ; had been  ill  six days;  and
for three days had vomited almost every thing he had taken.
After bloodletting and the other usual  remedies, his  headach
was very much relieved, and he was free from vomiting for
two days.  On the 7th  he was free from  headach, and his
look was natural;  but his pulse had fallen  to 48, and he had
occasionally double vision.  On the 9th he was  sitting up
and dressed ; his  pulse 60.   He  was  free from headach ;
tongue clean, and he had some appetite, but the double vision
was constant.
  (10th) Vision natural, in other respects  as before.
  (11th) Pulse  96 ; made no complaint,  but his  look was
vacant, and the pupils  were dilated; there had been  some
delirium in the night.
  (12th) Pulse  96 ; considerable delirium, vision natural.
  (13th) Increasing stupor.   (14th) Perfect coma, pulse 120.
Died on the 15th.
  Inspection.—All the ventricles were distended with  fluid.
The fornix was broken  down to a soft pulpy mass  which
could  not  be  raised.   The other parts of the brain were
healthy.
  Case LIV.—A gentleman aged 21, had been for  some
time affected with cough and occasional haemoptysis.  In the
beginning of December, 1823, he began to complain of head-
ach ;  he was not confined, but, on the  contrary, walked in one
day a distance of eight or nine miles after the headach began.
The headach increased gradually, but  he was not confined till
about  the 7th day.  From the 7th to the 14th day, he was
confined chiefly to bed, complaining  principally of sickness
and  giddiness, and occasional vomiting.   On some days there
was headach ; on others, little  or none.  On Monday the 15th,
he was up  and dressed for some hours, but had double vision.
On the 16th, he was oppressed and much  disposed to  sleep ;
the double vision continued.   I saw him for the first time  on
the 17th ; he was  then almost entirely comatose, with squint-
ing, the pulse below 60.  On the 18th,  after free purging,  he
revived  considerably,   and answered  questions distinctly;
squinting and double vision continued, with dilated pupil;  he
made no complaint of his head.  On the 19th, the pulse be-
gan to rise ; and there was a good deal of incoherent talking. 
110
ACUTE HYDROCEPHALUS.
On the 20th, there was constant  incoherent talking, with a
small rapid pulse, and he died in the night.  From the  com-
mencement of the head symptoms, his pectoral complaints had
entirely disappeared.
  Inspection.—There was partial ramollissement of the septum
lucidum and of both the thalami;  the ventricles were distend-
ed with fluid; the lungs were extensively tubercular, and there
were several small cavities containing a bloody fluid.

  Before leaving this  subject, it may be  right to add a few
cases illustrative of some of the most important varieties in the
symptoms, and showing the disease at various ages and under
various circumstances.

  Case LV.—Sudden attacks of coma without previous head-
ach—the pupils dilating on the admission of light.—A stout
boy aged 6, had been for several days feverish, and complain-
ed of pain in his belly.  After the operation of laxative medi-
cine, his pulse came down to the natural standard; he  con-
tinued  languid and listless, but made no complaint of any un-
easiness, and had never been heard to  complain of headach.
About  the 5th or 6th day of his illness, 10th July, 1816, with-
out any farther warning, he was found in the morning  in a
state of perfect coma,  speechless, and his pupils much dilated;
pulse 120.   He continued in  this  state of perfect coma, with
frequent convulsive  motions of  the left arm and leg, for six
days, and then died, his pulse  having continued steadily at
120 and upwards.  On the 12th and 13th, being the 9th and
10th days of the disease, the  pupils, which were partially di-
lated, were distinctly observed to dilate farther upon the  ad-
mission of light.
  Inspection.—The ventricles contained about four ounees of
fluid.  There was extensive ramollissement of the septum and
fornix, and of the cerebral substance immediately surround-
ing the ventricles ; this was most remarkable on the left side.

  ■Case LVI.— Two  distinct  periods of coma.—A  boy  aged
13, (13th June, 1822,) had slight headach, with some vomit-
ing and fever.  After four days, the headach increased and
the pulse fell to 60.—5th day,  Coma.   He  came out of the
coma on  the following day, and the only prominent symptom
was remarkable obstinacy of his bowels, which was only got
the better of after two days by repeated doses of croton oil ; 
ACUTE HYDROCEPHALUS.
Ill
he then seemed much relieved, made very little complaint of
his head, was quite free from stupor, and the pulse was natu-
ral.   On the following day, he complained rather more of his
head, then relapsed into coma, and died on the 12th day after
some convulsion.
   Inspection.—The ventricles were distended with  fluid, and
there was extensive ramollissement of the fornix and septum,
and of the lower part of the corpus callosum.

   Case  LVII.—Hydrocephalus, with  Hemiplegia.—A girl
aged 3, after being three days languid  and  complaining  of
some headach and pain in the  bowels, was first confined  to
bed on the-4th  June, 1822.   She was  oppressed, the pulse
100; there was some vomiting, and  she complained of head-
ach, which seemed to be referred  chiefly to the right side  of
the  head.   For a week the usual remedies were employed,
and there was little change in the symptoms.  On the 13th,
complete palsy took place in the left  arm and leg, which con-
tinued from this time entirely motionless, except at one time
when they were moved  by convulsion.   After  this, she  fell
into a  dozing state, with dilated pupil  and slow pulse;  but
complete coma took place only two days before death, which
happened on the 22d.
   Inspection.—The ventricles were distended with  fluid.   In
the substance of the right hemisphere, very near the ventricle,
there was a considerable portion in a state of complete ramol-
lissement ; and, contiguous to this, anteriorly, there was a long
and narrow portion of the cerebral substance in a state of re-
markable induration.

   Case LVIII.—In an adult, with very obscure symptoms, and
fatal after the coma had disappeared.  A lady aged 30, about
the 5th June, 1824, was exposed  to  cold and fatigue  during
the flow of the menses, which ceased prematurely.   After this,
she was for some days observed to be remarkably languid,
dull, and depressed.  The pulse was natural; she  complain-
ed of slight headach, but her appearance had excited  an  ap-
prehension rather of aberration of mind  than of any bodily
complaint; and in this manner the affection went on for 9 or
 10 days.  I saw her  on the  15th ;  she  was then odd in  her
manner, abrupt and absent, but quite sensible when spoken to;
complained of slight headach ; pulse a little frequent.   On the
 16th, she was much oppressed, and  on the 17th, in a state of 
112
ACUTE HYDROCEPHALUS.
nearly perfect coma, which continued on the 18th.   On  the
19th, after free purging with croton oil, she came out of the
coma entirely, was quite sensible to every thing, and no alarm-
ing symptom remained, except that she sometimes saw objects
remarkably distorted, and sometimes double.  At other times,
her vision was quite natural;  the pulse was frequent, and the
tongue loaded.  In this state she continued for several days ;
she then complained again of headach ;  there was occasional
incoherence; the sight was more indistinct, and the  pupil di-
lated ; and the pulse was increasing in frequency.  The pulse
continued to rise, with much incoherent  talking, and sinking
of strength ; and she died on the 25th without coma.
   Inspection.—The ventricles were  distented with fluid, and
there was extensive ramollissement of the septum and fornix.
There was no other morbid appearance.

   Case  LIX.—Remarkable remissions and apparent  convales-
cence.   A boy aged 7, (20th  October, 1824,) complained of
pain in the back of his head, with  fever and some vomiting.
Topical bleeding, purgatives, &c, were employed, and, after
being an object  of some anxiety for  several days, (a brother
having a short time before died of an affection of the brain,)
he gradually improved, and, on the 27th  and 28th, he was free
from complaint,  and going about the  house apparently in  his
usual health.   On the evening of the 28th, he was  suddenly
seized with violent convulsion, which returned through  the
night every two  hours, leaving him in the intervals in a state
of coma; the pupils dilated, and insensible.   On the 29th, he
was nearly comatose the whole day, the pulse weak, and  va-
rying in frequency from 60 to 120.   General and topical bleed-
ing, purgatives,  &c,  had been  employed.   (30th)  Became
quite  sensible ; the eye natural; pulse still frequent.   He com-
plained slightly of the  back of his head,  for which more topi-
cal bleeding was employed, with purgatives.  He then im-
proved progressively;  the  pulse was  from  80 to 90; and he
was free from complaint, except that the bowels were torpid
and the stools unhealthy, and that the pupil  was large, and
contracted slowly on the admission of light.   In this state he
continued several days, when the  convulsion  returned with
greater severity five or six  times, leaving him  as before in a
state of coma.   From  this he  recovered partially, but  sunk
gradually, and died in a few days.  For  two or three days be- 
ACUTE HYDROCEPHALUS.
113
 fore his death, there appeared to be considerable palsy of the
 left arm and leg.
   Inspection.—There was extensive effusion in the yentricles,
 and extensive ramollissement of the fornix.   The right lamina
 of the septum lucidum was in a state of ramollissement at the
 anterior part, occupying about the half of it; and the left la-
 mina was in the same condition  in its posterior half; there
 was no perforation.

   An interesting modification of this affection  is that which
 supervenes  upon other  diseases,  chiefly of a chronic  nature,
 especially affections of the lungs ; and the remarkable circum-
 stance in these cases is, that the pectoral symptoms generally
 cease after the commencement of the symptoms in the head.
 The three following cases will illustrate the principal forms of
 this affection.

   Case LX.—An ingenious artist, aged 30, had been affect-
 ed for some years with cough  and expectoration, which was
 decidedly purulent; but, though much confined to the house,
 he was able to attend to his business as an  engraver.   In the
 beginning of June, 1819, being one day considerably agitated
 in the discussion of some business in which he, thought him-
 self ill used, he felt uneasiness in  his head,  and soon after his
 speech became very indistinct.   The headach  increased, and
 was chiefly felt in the left side and back of the head, and the
 pain extended to the upper part of the neck ; his speech con-
 tinued much impaired ;  the pulse from 90 to 96.   The usual
 remedies were employed, with partial and  temporary benefit.
 The case was drawn out to  nearly three weeks, without any
 remarkable change in the symptoms.  He sunk gradually into
 coma, and died ; the pectoral complaints having subsided  as
 those in the head advanced.
   Inspection.—There was extensive effusion in the ventricles
 of the brain, and complete destruction  by ramollissement  of
 the septum lucidum, fornix, part of the  corpus callosum, and
 the cerebral  matter bounding the ventricles.  In  the upper
 part of each lobe of the lungs,  there was a portion of the size
 of a small orange in a  state of great induration, and internal-
ly presenting an irregular mass of ulceration;  the lungs  in
 other respects were' healthy.

   Case LXI.—A  gentleman aged 24, had been affected for
                           15 
114    RAMOLLISSEMENT of  the  central  parts,

about eight months with  cough and expectoration.  In  Au-
gust, 1824, he was seized with copious haemoptysis, and had
frequent attacks of it during August and September.  In Oc-
tober this ceased, but the cough continued severe, with copi-
ous purulent expectoration and great loss of flesh and strength.
In the  end of November, he began to  complain of headach,
which continued from this time to affect him considerably, ac-
companied by occasional vomiting; the cough and expecto-
ration continuing.  From this  time he became much less able
for exertion than formerly, but  no remarkable change was ob-
served  in the symptoms till the first week of January, when
one  evening he  suddenly lost  his speech.  He recovered  it
again next day, but complained of headach, and was  listless
and languid.   On  the third day he lost his speech again, and
recovered it on the 4th.   He lost it again on the 5th, and on
the 6th recovered it.  From this time  his speech  continued
tolerably distinct, but he  gradually sunk into a kind of fatuous
state, with occasional paroxyms of high delirium, and  repeat-
ed  convulsive affections of the face and upper extremities.
The pulse continued nearly natural;  the  expression  of the
countenance was remarkably vacant, and he  still  frequently
complained of his head.  He thus gradually sunk into coma,
and died in about three weeks  from the time when he first lost
his  speech.  From the commencement of this attack his cough
ceased entirely, until a few days before his death, when it re-
turned in a very slight degree.
  Inspection.—There was considerable effusion in the  ven-
tricles, and extensive ramollissement of the  septum,  fornix,
and adjoining parts.   Along the base of the brain,  there  was
an extensive  deposition of yellow adventitious membrane  of
considerable thickness.   There was extensive tubercular dis-
ease in both lobes  of the  lungs, with numerous large vomicae.

  Case  LXII.—A lady aged  28, had  been for some months
in winter 1823-24  affected with cough, considerable expecto-
ration,  some uneasiness  in the chest,  great loss of flesh and
strength, and quick pulse.  She came to Edinburgh about the
20th of May, 1824; the cough then  subsided remarkably,
which was ascribed by her friends to the  change of air, and
in a few days it entirely ceased.  She  then continued pretty
well till about the 27th,when she began to complain of headach,
and for the next three days she was dull  and silent, seemed
absent  and low-spirited, and complained that her  sight  was
dim.   She was partly in  bed, but her pulse was natural.  On 
4
OCCURRING IN PHTHISICAL CASES.
115
 the 31st, the pulse began to rise, and there was considerable
 incoherent talking.   I saw her for the first time on the fol-
 lowing day, the 1st of June ;  her look was then absent, va-
 cant, and  anxious,  and  she  talked a little incoherently, but
 understood what was said to her; there was  double  vision
 and slight squinting, the pulse very frequent.   (2d) Sight
 seemed much impaired, pupil dilated, much  wild talking at
 times, but  she knew those about her, and answered distinctly
 when spoken to; pulse rapid  and feeble, died in the night
 without coma.
   Inspection.—The  ventricles  of the brain  were distended
 with a large quantity of fluid, and there was  extensive ramo-
 lissement of the septum, and all the central parts.   About and
 above the optic nerves, there was a considerable deposition of
 coagulable lymph in a firm, dense, opaque  state.   The lungs
 were tolerably healthy in their structure, but there were marks
 of extensive chronic inflammation of the pleura on the right
 side, with considerable deposition of coagulable lymph.

   It is unnecessary to multiply cases which present no parti-
 cular  variety in  the  phenomena; those which have been de-
 scribed will probably seem sufficient to illustrate the principal
 forms of this affection, and  at the  same time to exemplify
 some  of the  most  remarkable varieties in the symptoms.
 From a fair and candid review of the whole  subject, I think
 we can have  little hesitation  in concluding, that this  is the
 ordinary form of the disease, which is commonly called acute
 hydrocephalus;  that it is originally an inflammatory affection,
chiefly seated in the substance  of  the  central parts of the
brain ; that it generally terminates by ramollissement of these
parts, combined with serous effusion  in  the  ventricles ;  and
that it may be fatal by the ramollissement alone, even of small
 extent, but with all the symptoms which  are  commonly con-
sidered as characteristic of acute  hydrocephalus.   The cases
likewise exemplify various important varieties in the symp-
toms.  We have seen in some of them, perfect coma of long
 continuance without any effusion ;  and  in  others extensive
effusion without any  degree of coma.  We have seen  again
the coma entirely removed, and yet the  disease go on to its
fatal termination.  We have seen every variety in the state of
the pulse, of the vision, and of the intellectual functions ; and
we have seen the disease run its course  without any com-
plaint of pain or any symptom indicative of danger, until the 
116
CASES  OF SIMPLE  EFFUSION.
patient was unexpectedly found in a state of profound coma.
These and many other varieties, presented by the cases which
have been described, shew us the danger of being guided by
system in our diagnosis of affections of the brain, and the ne-
cessity that there still is for extensive and careful observation
of facts in regard to this class of diseases.

  The form of the disease which has now  been described, I
conceive to be the  more common modification  of acute hy-
drocephalus ;  but it is to be kept in mind that serous effusion
takes place in the brain under other forms.   In some of these
it is connected with inflammatory affections  of other parts of
the brain or of the  membranes; but it may  take place with-
out exhibiting any other appearance, excepting the simple
offusion.  As a contrast to the  cases  now  described, I shall
add two examples of hydrocephalus which  presented simply
serous effusion in the ventricles, without any other  morbid
appearance in the brain ; and with regard to these two cases,
I think  it right to add, that  they are  the  only  examples of
this kind which I find among my notes of cases of idiopathic
hydrocephalus.   It will be seen that they exhibit the disease
in its most insidious and chronic form, and present a remark-
able  contrast to the active  symptoms in some  of the former
cases.

           §  V.—Cases  of simple effusion.

  Case LXIII.—A boy aged 9,  was  affected with slight
headach, foul tongue, bad appetite, and disturbed sleep ; pulse
from 96 to  100.   The  first  week of his illness was passed
with these slight symptoms;  he was one day  better and an-
other rather worse;  his headach was  sometimes gone for a
great part of the day, and  never severe.  Towards the end of
the second week there appeared to be a want  of correspond-
ence in the symptoms, the headach being greater and more
permanent than accorded with the degree of fever; but even
on the 13th and 14th days, the complaint had still  much the
appearance of the mildest form  of continued fever, and  was
considered in that light by a physician of the first  eminence.
During the second week, however, the headach  had become
more severe, while the other  febrile symptoms had been  di-
minishing.  On the 15th day the pulse sunk rather suddenly
to 70;  and the headach was increased.  On the  17th there 
CASES  OF SIMPLE EFFUSION.
117
 was coma, with some squinting; the pulse below the natural
 standard.  On the 18th the pulse began to rise, and the coma
 was diminished.   On the  19th  and 20th he was distinct and
 intelligent, tongue clean, some appetite,  pulse 96. On the fol-
 lowing day his appearance was less favourable;  he then sunk
 gradually into coma, with squinting, and died about the 30th
 day of the disease.  The pulse had risen to  120, and  in the
 last week there had been some slight return of convulsion.
   Inspection.—All the ventricles of the brain were found dis-
 tended with clear  serous  fluid ; there was no other morbid
 appearance, except considerable turgidity  of vessels on the
 surface of the brain.

   Case LXIV.—A gentleman  aged 24, was affected with
 slight headach, and unusual listlessness  and inactivity.  He
 ascribed the complaint to cold, and for the first week conti-
 nued to attend to his business.   In the  second  week he had
 considerable  headach, shivering, debility, bad appetite, foul
 tongue, and disturbed sleep, pulse about 112.  Towards the
 end of this week, his friends observed once or twice a slight
 and peculiar forgetfulness.   In the third  week his pulse came
 down rapidly to 72 ; his tongue became  clean; he made little
 or no complaint of his head, but there was occasionally a de-
 gree of incoherence, which was  slight  and  transient, and  a
 singular forgetfulness on particular subjects, which  was ob-
 served by his friends, but did not  appear in  his intercourse
 with his medical attendants.  The pulse  continued  slow for
 two days, and then rose rapidly to 130, with increase  of de-
 lirium.   After a few days more, the delirium again  subsided,
 and great hopes  were entertained of his  recovery; but the
 delirium soon  returned, and was rapidly followed by blindness,
 coma, and death.  He died about  the middle of the  fourth
 week of his illness.  I  did not see  this patient daring his
 life, but was present at the examination of the body.
   Inspection.—All the ventricles of the brain were found dis-
 tended with clear serous fluid, without any other morbid ap-
 pearance.

   The  pathology of cases of this kind is perhaps  more
 obscure, than that of the cases formerly referred to ; but that,
in these cases  likewise,  the effusion arises from a low degree
of inflammatory action in the brain, is probable from the fact,
that similar appearances are occasionally  met with in those in- 
118        GENERAL REVIEW OF  THE  SUBJECT.
stances in which the disease supervenes upon injuries of the
head, as in the following cases.

  Case LXV.—A man aged 40, of a scrofulous  habit, was
standing on a  cart at Leith races, when the horse moving for-
ward, he lost his balance and fell out of the cart, striking his
head upon the sand.   He  felt at the time no  inconvenience,
and for a week attended to his business, but complained fre-
quently of headach.   He was then confined to the house from
increase of headach, with  vomiting, and slight fever; after a
few days, he became oppressed, then  comatose, and died at
the end of the second week.
  Inspection.—All the ventricles of the brain were found dis-
tended with serous fluid, without any other  morbid  appear-
ance.

  Case  LXVI.—A girl  aged 13, fell from  a  swing, and
struck her head with some violence  on the  ground.  From
that time she complained of  headach,  but was not confined,
nor was her health otherwise affected, until six weeks after
the  accident, when her headach increased, and was accompa-
nied by vomiting and  frequent pulse.   The vomiting soon
subsided, but was followed  by slight delirium, and  this by
coma.  She lay in a state  of coma for five or  six  days, and
then died, two months after the fall.
  Inspection.—All the ventricles of the brain were found dis-
tended with serous fluid,  without any other morbid appear-
ance.

  A general review of this important  subject seems  to lead
to some results of much practical importance in the pathology
of affections of the brain,  particularly in regard to  that class
of them which terminate by  effusion.  There  are  many facts
on record, which shew us the presence of fluid in the  brain in
large quantity, without any alarming symptom having resulted
from it.  Morgagni found eight ounces in a man  who died
suddenly of suffocation in  an advanced stage  of pneumonia ;
and Dr. Heberden found the same quantity in a man who died
suddenly,  after being weakened by a  febrile  attack, without
any symptom  of an affection  of the brain.  It is therefore not
the mere presence of a certain quantity of fluid in the brain, that
gives rise to the symptoms  of hydrocephalus, and on the other
hand, we have seen a disease go through all the usual symp-
toms of hydrocephalus, and terminate fatally without any effu- 
           GENERAL REVIEW OF  THE  SUBJECT.        119

sion.   The fair conclusion  from these  facts appears  to  be,
that the prominent  symptoms  in  these cases are not the re-
sult of the effusion,  but of that disease  of the brain of which
the effusion  is  one  of the  terminations.  From  a variety
of facts which have been adduced, there seems little reason to
doubt  that  this  disease is of an  inflammatory  nature.   If
these conclusions shall be  considered  as  well  founded, it
will follow, that our  practice ought to be directed principally
to subduing the inflammation at its earliest period, and pre-
venting it from passing into effusion,  and  particularly from
passing  into ramollissement, which  we have seen to be  a
fatal termination of  the disease even though of small extent
and without any effusion.  This termination, I think, we have
every reason to consider as the result most to  be  dreaded in
this class of  the inflammatory  diseases  of the brain; for in
regard to the  mere  effusion, were the  parts otherwise in  a
healthy state, there does not seem to be any very  satisfactory
reason for considering  it as a  hopeless affection.   In other
words, I mean  to submit, that-we  have no good reason for
doubting the possibility of serous fluid  being  absorbed from
the ventricles of the  brain.  We are  warranted in this  sup-
position, both by the analogy of other serous cavities, and by
what we actually see take place in the brain itself.  In the
other serous  cavities, We have every reason to believe, that
there is constantly going on an obsorption of the old fluid,
and a deposition of  new fluid in its place; and we see them
in a state of disease, relieve themselves by an increased  ab-
sorption from an excess of fluid which has been deposited.
The ventricles of the brain are unquestionably to be consider-
ed as serous cavities ; and there  seems to be no good reason
for considering them as differing  in their functions from the
other cavities of the  same kind, whatever the particular appa-
ratus may be by which  the function is carried on.  In regard
to the  actual  existence of absorption in the brain, we have the
most satisfactory proof, in the  gradual  disappearance of co-
agula of blood, both from the surface and from the ventricles,
and from the cavities in the substance  of the  brain.   Upon
the whole, I think we have  sufficient ground for receiving the
following conclusions in regard to this class of affections of
the head.
   1st, That in the ordinary cases of hydrocephalus, the coma
and other symptoms attending it are not to be considered as
the direct effect of the effusion, but of that morbid condition
of the brain of which tlie effusion is the consequence. 
120         GENERAL REVIEW OF THE SUBJECT.
         2d, That we have no certain mark which we can rely upon
       as indicating  the presence of effusion in the brain.  Slowness
       of the pulse  followed by frequency, squinting, double vision,
       dilated pupil, paralytic symptoms, and perfect coma, we have
*      seen may exist without any effusion.
         3d, That all  these symptoms may exist in connexion with
       a state of the brain, which is active, or simply inflammatory,
       while the disease is the subject of active treatment, and while
       by such treatment, adopted with decision at an early period,
       we have the prospect of arresting its  progress in  a considera-
       ble proportion of cases.   The ground of prognosis in particu-
       lar cases depends perhaps in a great measure upon the activity
       of the symptoms.   The more they approach to the character
       of active inflammation, our prospect of cutting them short will
       be greater; and the more they partake of the low scrofulous
       inflammation, it will be the less.   In all  of them, the period
       for active  practice is  short, the irremediable  mischief being
       probably done at an early period of the disease.
         These principles bear immediately upon the question, Has
       hydrocephalus been cured?  There  is no doubt that many
       cases have recovered, which exhibited all the usual symptoms
       of it, several  examples of  which will be mentioned in the se-
       quel.  Such  cases  have by some been confidently  brought
       forward  as examples of hydrocephalus cured, while others
       have only considered them as  remarkable  from their  singular
       resemblance to that disease.   If the principles now referred
       to be  admitted, we  shall see  reason to believe, that we have
       no certain rule by which we can decide upon the presence of
       effusion in the brain; but that all the symptoms usually attend-
       ing it exist in connexion with  an  inflammatory condition  of
       the brain, which, if  allowed to go on, would probably lead to
       effusion, but which, if treated  with decision in its early stage,
       may, in a certain proportion of cases, be treated with success.
       Whether the fluid  can be absorbed, or the disease cured, after
       effusion has taken place,  must remain matter of conjecture;
       but, from the  facts which have been adduced, we have every
       reason to believe, that in the ordinary cases of hydrocephalus,
       the removal of the fluid, if it  did take place, would in no re-
       spect  improve the situation of the patient,—because there
       would still remain that deep-seated disease of the central parts
       of the brain, which  accompanies  the  effusion in so large a
       proportion of  cases, and which we have  seen may be fatal
       without any effusion, yet with all the -usual symptoms of hy-
       drocephalus. 
INFLAMMATORY AFFECTIONS OF THE BRAIN.    121
                      SECTION  VII.

OF TH*E CAUSES OF THE INFLAMMATORY AFFECTIONS OF THE
                          BRAIN.

   In a great proportion of the cases of the inflammatory af-
fections of the brain, the causes elude our observation;  the
circumstances under which  they most  frequently occur,  are
chiefly the following:
   I, They often appear in the course of other febrile diseases,
as continued fever, scarlatina, measles, &c.   One of the most
frequent  and most severe  examples  of  the disease  arising
from this source, is an affection which supervenes upon scar-
latina,   A child  recovering from scarlatina, which may have
been in a mild  form, is seized, perhaps  after some exposure
to cold, with headach, which after a short time is followed by
convulsion, and  this by blindness and coma.  These  symp-
toms may have been preceded by the anasarca which frequent-
ly supervenes upon scarlatina, and on that account, are apt to
be ascribed to sudden effusion in the  brain;  but  the disease
is entirely inflammatory, and  the patient can be saved only by
the most vigorous treatment,—by bloodletting, purgatives, and
other similar remedies.  Upon this plan, many such cases re-
cover; others die and present the usual  appearances of the
inflammatory affections of the brain; and  some of those who
have recovered from the affection, have been afterwards liable
to epileptic paroxysms.  A similar disease occurs in continu-
ed fever, especially in the more advanced  stages of it.   If it
has come on  gradually and insidiously, it is  generally hope-
less ; if it be  in a more acute  form, the patient may frequently
be saved  by active treatment.  In connexion with low  and
protracted fever, however, a condition frequently occurs, which
puts on  many characters of  the most dangerous affections of
the brain, but these pass off when the fever subsi les.   A  boy
between  4 and 5, whom I saw with  Dr. Begbie, with  much
of the character of low fever, had  stupor followed by dilated
pupil and blindness with some squinting;  he then had loss of
speech;  and after lying completely  speechless for,nearly a
month  gradually recovered.    The blindness continued only
                            16 
122     INFLAMMATORY AFFECTIONS OF THE BRAIN.

six days :  the recovery of his speech was preceded by copious
discharge  of  matter from both his ears.  About three months
after, he died in the country of a head affection, and tubercu-
lar disease was found in the brain, with effusion.   In another
case, in an adult, which terminated favourably, there was for
several days nearly perfect coma, with that spasmodic rigidity
of some of the limbs, which the  French have considered as
characteristic of ramollissement of the brain.

   II. They may follow injuries,  and this  perhaps is a more
frequent cause  of the  affections than we are generally aware
of, especially in children;  the injury being  often slight, and
the interval very considerable betwixt it and the appearance
of any alarming symptoms.  I have given two remarkable ex-
amples which seem to be referable to this head in cases LXV.
and  LXVI.

   III. Suppressed  evacuations.   One of the most common
examples of this is suppression of the menses, which in young
women  of unsound constitution is very often followed by dan-
gerous affections of the brain.   Headach,  or any symptom in
the head occurring under such circumstances, is always to be
considered as requiring most minute attention.  Case LVIII.
affords an interesting example of the  disease  coming on in
this  manner, and running its  course with a very remarkable
train of symptoms.   Another affection which seems to be re-
ferable to  this head,  is that effusion in the brain  which is apt
to supervene upon urinary disorders,  particularly on that re-
markable  affection, the Ischuria Renalis.   In this obscure dis-
ease, the  prominent  symptom is a very sudden diminution of
the secretion  of urine, amounting frequently almost to a com-
plete suspension  of  it.   Generally about the third  day from
the occurrence of this  symptom, the patient is found passing
into  a state of coma, in which after a few  days more he dies.
The ventricles of the brain are found distended with fluid.   In
the following singular  case, the same symptoms supervened
upon another and rather  uncommon modification of the dis-
ease, namely, Ischuria  Ureteralis.

   Case LXVII.—A gentleman aged 70, (in February, 1816,)
complained to me  that he could pass no urine ;  he made no
other complaint, and on introducing a catheter, the bladder
was  found to be empty.  For six days he continued in this 
CAUSES.
123
state, keeping the house, but complaining of nothing, except
once or twice, when closely questioned, of slight uneasiness
in his back.  On the seventh day, he had slight confusion of
thought, and indistinctness of speech.   On the 9th, he became
comatose, and died on  the  13th.   On dissection, extensive
effusion was found in the ventricles of the brain; the bladder
was empty.  Both kidneys were distended with urine.  Both
ureters were  completely obstructed by large calculi, the  one
immediately at its upper extremity, the other about three inches
below the kidney.

   IV.  The affections often occur in connexion with disease of
a chronic or scrofulous character in other parts of the body.
The most frequent example of this is, the brain becoming af-
fected in the advanced stages of phthisis.  Of this I have giv-
en several examples, and I have seen many more, assuming
various characters.   In one of them, the head symptoms be-
gan a month before death, with  attacks of loss  of  speech,
which continued only a few minutes at a time, and were  ac-
companied by a sensation of prickling and numbness of the
right side  of the face.   After  the patient  had been liable to
these attacks for a fortnight, he had headach and slight deli-
rium, followed by stupor, which was fatal in another fortnight.
In another man, aged  32, who  had been ill five weeks  with
severe  pulmonary complaints, the first symptom was double
vision, without headach.  He complained of dysuria, and his
 pulse was irregular.
   In such cases  the  first disease is  not properly to  be  con-
 sidered as the cause of the head affection.   It merely marks
 the tendency to inflammation of a chronic  or scrofulous  cha-
 racter ; and, in  habits so disposed, the affection of the brain
 may be excited by causes which  elude our observation.   On
 the same  principle, disease in the brain may appear in con-
 nexion with  disease of any other organ, especially in un-
 healthy children.   In such cases the liver has often been found
 diseased; and, founded upon this observation, diseased liver
 has been  improperly stated as one of the causes of hydroce-
 phalus.  The same observation perhaps applies to worms and
 various other affections of the bowels, which in unhealthy
  children are often  found to accompany hydrocephalus, and
  have  sometimes been  considered in the relation of  a cause.
  Some  of  the more acute affections  of the bowels, however,
  seem to be entitled to  more attention, though the connexion 
124     INFLAMMATORY AFFECTIONS OF THE BRAIN.

betwixt them and the affections of the brain is very obscure.   In
some of them, it perhaps merely arises out of the general fe-
brile excitement of the system ;  but, in others, there seems to
be a connexion distinct from this.  One of the most remarka-
ble examples is in the inflammation of the mucous membrane
of the  bowels,  which occurs in young children of the age of
from eight to twelve months.   This  affection  frequently ter-
minates by coma, and the coma appears to be frequently pre-
ceded  by a remarkable diminution of the secretion of urine.
I have elsewhere thrown out a conjecture that this disease, in
its relation  to the  affection of the brain, bears an analogy to
ischuria renalis, but perhaps  the  connexion in both cases is
equally obscure.
  In the dissection  of cases of  hydrocephalus in  young chil-
dren, we very often meet with  inttis-susceptio in  the bowels,
and it  generally exists in  several places.   I have repeatedly
seen six or seven of them, and  in one case fourteen.  They
appear in general to be quite  recent, being free from inflam-
mation or thickening of the parts ; and in the cases which oc-
curred  to me, there  did not exist any unusual obstinacy of the
bowels.  The  affection, therefore, is probably to be consider-
ed as recent and incidental; or perhaps, as arising out of  an
inversion or derangement of the peristaltic motion  of the bow-
els.  This  may be  produced by the affection of the brain in
the same manner  as, we see urgent vomiting connected with
it.  In some cases, however, the intus-susceptio  appears  to
have been of longer standing, and to have preceded the affec-
tion of the brain.   A,girl aged  6  years, mentioned by Dr.
Coindet,* had  sfvere pain in the belly, vomiting, and con-
stipation ; on the fifth day, head symptoms appeared, and she
died on the  12th.   Much effusion was found in the brain, and
there was an extensive intus-susceptio in the ileum,  where a
portion of  intestine, six or seven inches long, was inflamed
and thickened.

   V.  Various other causes might be mentioned, such as pas-
sions of the mind,  stimulating liquors, &c.;  but I shall not
enter upon these, and  shall only add one which is  of frequent
occurrence, and presents some singular phenomena,  namely,
exposure to the intense heat of the  sun.  It appears that in
some cases of this  kind, the  membranes are chiefly affected,
and in others the substance of the brain.  Sometimes an apo-
* Coindet, Memoire sur l'Hydrencephale. 
     TREATMENT OF INFLAMMATORY AFFECTIONS, ETC  125

plectic state is produced, which is fatal in a few hours;  but,
more frequently, an affection of an inflammatory nature, occa-
sionally assuming the character of mania ; and in others, pa-
ralytic symptoms occur at an early period followed by coma.
The affection of course is chiefly a  disease of warm climates,
but also occurs  in this country,  as in the following case, for
which  I am indebted to Mr. Clarkson, surgeon in Selkirk.

   Case LXVIII.—A  young man aged  15,  on the 5th of
June, 1818, bathed twice in the river Tweed.   After  coming
out the second time, he lay down on the bank and fell asleep
without his hat,  exposed to the intense heat of the sun.  On
awaking, he was speechless, but walked home, and seemed to
be otherwise in good health. He was bled and purged, and next
day recovered his speech, but lost it again at intervals several
times during  the three or four following  days.  *He was  for-
getful, and his look was dull and heavy;  he made little com-
plaint, but, when closely questioned, said he had a dull unea-
siness in the back part of  his head.  After  a few days more,
he had squinting and  double vision, with a very obstinate state
of bowels, and his pulse was 60.  After farther bleeding, &c,
the pulse rose to 86, but he  sunk  gradually into coma,  and
died on the 30th.
  Inspection.—The substance of  the brain in general  seemed
highly vascular,  and a very considerable extent of it was  in a
state of ramollisement mixed with suppuration.   The ventri-
cles were  distended with fluid,  and the membranes in many
places  were much thickened.  The inner surface of the crani-
um was very unequalxt the  upper part, frnd one spot, the
size of a sixpence, was as thin as writing paper, and transpa-
rent.
                    SECTION VIII.

OF  THE TREATMENT OF THE INFLAMMATORY AFFECTIONS OF
                       THE BRAIN.

  In the treatment of this important class of diseases the re-
medies are few and simple ;  but every thing depends upon the 
126    INFLAMMATORY AFFECTIONS OF  THE BRAIN.

use of them being adopted at an early period, and in the most
decided manner.  Those on which we chiefly rely are blood-
letting, general and topical—active purgatives, and cold appli-
cations to the head.  Benefit is also derived from antimonials,
and, in some states of the disease, from the digitalis. The ef-
fect of blistering in  the early stages is rather ambiguous.—
When it is employed, it should perhaps be on the back part of
the head and neck; in  these  situations  it is  probably more
likely to be useful than on the upper part of the head, while
it does not interfere with a more powerful remedy, the appli-
cation of cold.   After the first activity of the disease has been
subdued, blisters applied in succession to various parts of the
head, and the upper part of the spine,  appear  to be in many
cases extremely useful.  Mercury has been strongly recom-
mended  in that class of cases which terminate by hydrocepha-
lus,  but its reputation  seems to stand  upon  very doubtful
grounds.   In many cases,  especially during the first or more
active stage, the indiscriminate employment of merc#y must
be injurious.   In the  adaptation of  the particular remedies to
individual cases, we must of course be regulated by the age
and habit of  the patient, and  particularly by the character of
the disease in regard  to  activity.  In those cases which as-
sume the  more acute or active forms,  general bloodletting
must be used in the most decided manner ; while in the cases
which assume a more chronic character,  as many of the com-
mon cases of hydrocephalus, it has less  control over the dis-
ease, and is not borne to the same extent.   In all the forms of
the  disease,  active purging appears to  be the remedy from
which we find the most  satisfactory results; and although
bloodletting is never  to be neglected  in the earlier stages of
the disease, my own experience is,  that more recoveries from
head affections of the most alarming aspect take place under
the use of very strong purging, than under any other mode of
treatment.  In  most of these cases indeed full  and repeated
bleeding had been  previously employed, but without any ap-
parent effect in  arresting the symptoms.  The most convenient
medicine for this purpose is the croton oil.  In regard to local re-
medies, by far the most powerful is the application of cold.—
It may be applied in  a continued manner by means of a blad-
der containing pounded ice  mixed with a small quantity of
water; but a still more effectual mode of applying it  in the
 more acute cases, is by a stream of cold water directed against
the crown of the head, and continued for a considerable time, 
TREATMENT.
127
until the full effect be produced from it.  Applied in this man-
ner, it is a remedy of such power, that  it requires to be used
with much discretion.   Under the operation of it, I have seen
a strong man thrown, in a very few minutes, into a state ap-
proaching to asphyxia,  who  immediately before had been in
the highest state of maniacal  excitement, with morbid increase
of strength, defeating every attempt of four or five men to re-
strain him.  The following case shows the immediate effect of
it in another modification of the disease.  A  strong plethoric
child, aged five years, after being one day feverish, oppressed
and restless, fell rather suddenly into a state of  perfect coma.
She had been  in this  state about an hour when I saw her;
she lay  stretched on her back, motionless and completely in-
sensible ;  her face flushed and turgid.   She was raised into a
sitting  posture,  and, a  basin being held under the  chin,  a
stream of cold water was directed  against the crown of the
head.   In a few minutes,  or rather seconds, she  was com-
pletely recovered, and next day was in her usual health.  The
same remedy I am in the habit of  using with the best  effect
in the convulsive diseases  of children ; and it appears to be
much more useful in  such cases than the warm bath, the in-
discriminate employment of which is  often decidedly inju-
rious.
   In the preceding observations, I  shall perhaps be consider-
ed as having attached too little importance to mercury in the
treatment of this class of diseases, particularly in the treatment
of hydrocephalus ; but in doing so, I have stated simply what
is the result of an extensive observation.  When mercury was
first employed as a  remedy for hydrocephalus,  it was  given
with  a  view to   promote the absorption of the effused fluid,
which was supposed to constitute the essence of the disease;
it is now  given to correct the biliary secretion, and the func-
tions of the digestive organs, which, according to certain mo-
dern doctrines,  hold so prominent a place in almost every
class of diseases.   In affections of the brain,  as in all other
diseases,  it is highly proper that these secretions should be at-
tended  to, but it is not thus that we are to expect to cure hy-
drocephalus ;  and I  confess the result of my own observation
is, that when mercury is useful in affections of the brain, it  is
chiefly  as a purgative.
   Under  the treatment  which I have now mentioned, I have
seen many cases recover  which exhibited all the usual symp-
toms of the most dangerous  affections of the brain, and  even 
 128    INFLAMMATORY  AFFECTIONS OF THE BRAIN.

the most advanced stages of them. The cases which thus ter<
minate favourably, form, it must be confessed, but a small pro-
portion of those which come under the view of a physician of
considerable practice ; but they hold  out every encouragement
to persevere in the treatment of a class of diseases, which, af-
ter a certain period of their progress,  we are too apt to consi-
der as hopeless.   I shall conclude this part of the subject by
a selection of  cases illustrating the favourable termination of
the disease in  various forms, and under the most unpromising
circumstances.  Some of these will show the affection arrest-
ed in the early or acute stage,  while others will  illustrate the
favourable termination of it with  the symptoms which have
usually  been  considered  as characteristic of the more ad-
vanced period, in which  the affection is generally considered
as hopeless.   When these cases are  compared  with the fatal
cases which have already been described, there will, I think,
appear to be every reason for  considering them as fair exam-
ples of this dangerous affection of the brain.
                 #
   Case LXIX.—A girl  aged 11, had violent  headach  and
vomiting, with great obstinacy of the bowels, and these symp-
toms were followed by dilated  pupil, and a degree of stupor
bordering upon perfect coma ; pulse 130.   She had been ill
five or six days; purgatives, blistering,  and mercury to sali-
vation had been employed without benefit. One bleeding from
the arm gave  an immediate turn to this case ;  the  headach
was relieved,  the pulse came down, the vomiting ceased;
the bowels were  freely acted upon by the medicines which
they had formerly resisted; and in a few days she was quite
well.

   Case LXX.—A  slender and delicate  girl, aged 11, had
scarlatina in a favourable form in the beginning of April, 1820.
About the 16th, she was  so much recovered as to be allowed
to go about the house.  A few days after this, she was affect-
ed with anasarca, for  which she took  some medicine with par-
tial benefit. About the 26th, however, the anasarca had again
increased considerably, especially in the face, which  was very
much swelled.  In the following  night she  had vomiting.—
On the 27th, she complained of headach, which increased ra-
pidly in violence ;  towards the afternoon, she became delirious,
the pulse very  frequent, about 160.   Soon after this she was
seized with  violent and general  convulsion, which  recurred 
TREATMENT.
129
very frequently through the night, leaving her in a state of
profound coma.  The treatment adopted during the course of
these symptoms was repeated general bleeding, to the amount
of 28 ounces, followed by topical bleeding, purgatives,  anti-
monial solution, &c.  Towards midnight the convulsions ceas-
ed, and some  time afterwards she  gradually recovered  from
the coma. On the 28th, she was free from any alarming symp-
tom during the early part of the day ; pulse about 108.   In
the evening she was  seized with severe symptoms of pneu-
monia, on account of which she was  bled during the next 24
hours to the amount of upwards of 30 ounces, besides bleed-
ing with leeches and the other usual remedies.   In a few days
more she was restored to perfect health.           •

   Case  LXXI.—A young man aged 16, in the beginning of
October, 1823, had cough with severe dyspnoea, for which he
was freely bled from  the arm with much  relief,  and on the
morning of the 10th, he was considered as convalescent.  In
the evening of that day he had headach ""and  some vomiting.
About midnight, having got out of bed to  go to stool, he fell
down in a state of violent and general convulsion.   The con-
vulsion returned during the night six or seven times with such
violence that one of the attacks continued without intermis-
sion for about an hour.  The pulse during the  night varied
from 60 to 120. At first it was found impossible to bleed him
on account of the violence of the convulsions, but about 7 in
the morning a full bleeding was obtained,  though with  some
difficulty, after which the convulsions  ceased,  except  some
slighter attacks during the day, which appeared to be arrest-
ed by pouring cold water over his  head.   During the  11th,
he was oppressed, with occasional  tremors of the limbs and
some vomiting, and he had one or two threatenings  of convul-
sion ;  pulse about 80 and soft: he  took repeated doses of ac •
tive purgatives with  little effect,  and on the morning of the
12th he appeared to be sinking into a state of perfect coma;
pulse 50.  Croton oil was now given, which operated power-
fully seven or eight times.   He passed a good night, and on
the 13th was free  from complaint.   This very important case
was under the care of Dr. Huie.  I  saw the patient along with
him from mid-day of the 11th.

   Case LXXII.—A gentleman aged 21, was  first  affected
with confusion of thought and very considerable loss of recol-
                            17 
130     INFLAMMATORY AFFECTIONS OF THE BRAIN.

lection.  He then complained of headach, and after a day or
two  had double vision, the two objects being placed the one
above the other.  At this time he was out of bed the greater
part  of the day, but was restless and confused, and at times
incoherent.  He was then confined to bed, and had constant
headach, much incoherence and oppression, the double vision
continuing.  The pulse was at first frequent, but fell gradual-
ly, and sunk below the natural standard;  and the symptoms
went through a course exactly similar to that which has been
described in many of the fatal cases.   As the pulse fell in fre-
quency, he became more and more oppressed, until he sunk
into  a state of stupor, from which he could scarcely be roused
so as to answer a question of the most simple kind.  The case
went on  in this manner for eight or ten days, during which
time he was treated by repeated general and topical bleeding,
cold applications, blistering, &c, without  the  smallest effect
in arresting the progress of the symptoms.   The bowels were
very obstinate, and large doses of the most active purgatives
were given with little  effect.  He seemed to be on the brink
of perfect coma, and the case was  considered as desperate,
when he began to take the croton  oil, in full doses, repeated
every two or three  hours.  In  a few hours, he was purged
very actively nine or ten times ; the same evening he was re-
lieved  from every alarming symptom, and in a few days was
free  from the complaint.

   Case  LXXIII.—A girl aged 2 years  and 3 months, previ-
ously very strong and healthy, had  recently recovered from
measles, when about the 7th July, 1821, she suddenly lost the
power of both her lower extremities.  She continued without
any  improvement, but without any further  symptom, till  the
beginning of August, when she became affected with squint-
ing  and  drowsiness, and her countenance was expressive of
fatuity.  On the 7th, she was seized with smart fever, urgent
vomiting, and  frequent  slight  convulsions; the face flushed,
the pulse strong and frequent.   She was treated by Dr. Begbie
by bleeding and purgatives ; and on the 8th, she was consi-
derably relieved.   On the 9th, however, the symptoms return-
ed, with stupor bordering  upon coma,  oppressed breathing,
and  dilated pupil.  The squinting continued, with complete
palsy of the lower extremities.   Farther  bleeding with leech-
es was now employed, and  active  purgatives,  followed by
blistering on the  neck, and under this treatment the more ur- 
TREATMENT.
131
gent symptoms speedily disappeared.   The palsy of the lower
extremities then subsided gradually, and was entirely removed
in about three weeks.

   Case  LXXIV.—A  lady aged 45, after the menses  had
ceased for four months, was seized with  headach, sense of
weight in the head, much oppression and double vision : the
pulse was at first 72, but soon rose to 100.  On the first day,
she was bled to twenty-eight  ounces, with little relief.  On
the 2d, topical  bleeding, blistering, and smart purging were
used, but the symptoms continued unabated.  On the 3d day,
another bleeding  of twenty ounces  gave a turn to the com-
plaint, and in a few days more, with  brisk purging and spare
diet, it terminated favourably.  The last symptom that yielded
was the  double vision.  It subsided slowly, the two images
gradually approaching  nearer to each  other, but it was not
entirely gone for nearly a fortnight.

   Case LXXV.—A girl aged 7, had severe headach, impa-
tience of  light, fever and slight delirium, followed by stupor,
squinting, and  great obstinacy of the bowels.    The tongue
was at first foul, but became clean after a day or two.  Topi-
cal bleeding and blistering were employed, with various active
purgatives, which  produced little effect; and the symptoms
continued unabated for a week, during which she was con-
sidered as being in a hopeless state of hydrocephalus.  At the
end of the week, strong purging being  produced, she  reco-
vered rapidly, and in-a few days was free from the complaint.

   Case  LXXVI.—A  young  lady aged  11,  of a family in
which several had died of  hydrocephalus, on September 21,
1817,  had severe  headach, giddiness, and much vomiting;
the pulse  natural.  After topical bleeding and purgatives, she
was relieved on the 22d.  On the 23d, she still complained of
headach, and the pulse fell to 60.   On the 24th, the  pulse
fell to  50; there was much headach, with great oppression
approaching to coma, and dilatation of the pupil.  Two bleed-
ings from the arm  were now employed with much relief; the
second produced syncope.   On the  25th, the pulse was from
80 to  90, and  all the  symptoms were relieved.   The  com-
plaint then subsided under the use of purgatives and cold ap-
plications ; and in five or six days more she was in her usual
health. 
132     INFLAMMATORY AFFECTIONS OF THE BRAIN.

  Case LXXVII.—A lady aged 15, had  violent headach for
several days, with  impatience of light, followed by transient
fits  of delirium;  and this by squinting,  double vision,  and
stupor hording upon  coma; the bowels very obstinate, with
occasional vomiting.  The pulse was  very variable, being
sometimes extremely frequent, and at other times little above
the natural standard.  There  occurred  paroxysms of violent
aggravation  of the pain, which  produced  screaming and agi-
tation of the whole body, and at  times there was a threatening
of convulsion.   This very violent case was treated by repeat-
ed general  and  topical bleeding, blistering, purgatives, and
mercury given so as to affect the mouth.   Under  this treat-
ment  the complaint subsided; but after  she appeared to be
well,  it suddenly returned with the same  violence as before,
and was again treated by the same remedies.  In this manner
she relapsed five or six times, and  at last got well  after the
case had been drawn out to many weeks.

  Case  LXXVIIL—A lady aged 21, in July,  1815, had
symptom^ of continued fever, which went on for three weeks.
The  pulse then  came down  to 84, and the tongue  became
clean, but she had much headach, transient fits of delirium,
and stupor bordering upon coma, and the pulse  rose again to
120.   In this  state she continued a fortnight, with every ap-
pearance of  an affection.of the  brain of the most formidable
character, and without being  at all  relieved by the remedies
which were employed, namely, repeated  topical bleeding, blis-
tering, and large doses of calomel.  The  calomel did not af-
fect the mouth,  and had very little effect upon the  bowels.
At the end of  the fortnight she was  suddenly seized with co-
pious  discharge of blood  from the bowels.  This  continued
three  days, and left her extremely pale and exhausted, but she
was free from stupor, and the headach was much relieved. In
five or six days more she was well.

  Case LXXIX.—A gentleman aged 17,  1st February, 1810,
had symptoms of continued  fever for a week;  the skin then
became cool and the tongue  clean;  but he had severe head-
ach with considerable stupor; pulse 100.   Genera]  bleeding
was then employed, followed  by purging and mercurial fric-
tions ; and after a few days the symptoms were  alleviated;
but there was still  much headach, with oppression, and a re-
markable slowness of speech.  On the 14th, there was increase 
treatment.                   133
of stupor;  pulse  86; the tongue clean;  the skin cool.  On
the 16th, there was much incoherent talking and unmanage-
able delirium; after which the stupor  again  increased, the
pulse continuing  about  84.   On the 19th, there was partial
relief after smart purging; but on the 20th, the stupor had re-
turned as before, and by the  22d, had increased to perfect
coma; the pulse about 100.   He now lay  in a state of perfect
coma for four days, during which time various medicines were
given with  difficulty, and with little effect upon  his bowels.
On the 27th,  purging was at last produced to the extent  of
fourteen  evacuations in  the course  of the day,  with complete
relief of all his symptoms.  On the 28th,  there was some de-
lirium, which subsided in another day.   For a week he con-
tinued to complain of some headach, and a feeling of weight
in his head; but by the  10th of  March, he  was free from
complaint.

  To these cases, as they stood in the former edition, I shall
only add the following, which presents some features of much
interest.                                           *

  Case LXXX.—A boy aged 12, the son of a medical friend,
had scarlatina mildly in  the spring  of 1833.  Nearly a month
after, he was affected with slight anasarca of the face, and af-
ter  this had continued  several days, he had some vomiting,
and appeared languid.   About a week after the appearance of
the anasarca, he complained one morning of headach, and had
some vomiting; pulse slow and rather languid.  About eleven
o'clock in  the forenoon, he suddenly lost his  sight;  and to-
wards the afternoon, he passed into a state bordering on coma.
He still complained of headach, but the pulse  was not above
the natural  standard, soft and languid.    Topical bleeding
having been employed without relief, I saw him at night, and
advised general  bleeding  to 12 ounces to be followed by ac-
tive purging, and cold applications to the head.   During the
bleeding the pulse rose both in strength and frequency.  Next
morning I found him quite sensible, but entirely blind ; there
was still some headach,  but less than formerly, and the pulse
was stronger, and not  frequent.   He was  again bled to  12
ounces, and the purgatives repeated.  After five or six evacu-
ations from the bowels,  his sight began to  return, and in the
evening  was entirely restored.   Next day he  was free from
complaint,  and has ever since enjoyed good health. 
APPENDIX

         TO

   PART  FIRST.
  The  preceding observations conclude  the present imper-
fect  outline of the first part of our subject, The inflam-
matory affections of  the brain.    Before  proceeding
to the second part, I shall introduce in this place a few ob-
servations upon certain affections, which  are most allied to
the first class, and in a practical point of view are often ob-
jects of wery great interest; they are referable to the following
heads:
  I. Tubercular Disease of the Brain.
  II. Certain Affections of the Bones of the Cranium,
  III. Certain Affections of the Pericranium.
                       SECTION  I.

         OF TUBERCULAR DISEASE OF THE BRAIN.

  When we have an  opportunity of observing tubercles in
the brain in their early stages, in consequence of the patient
having died of some other disease, we find them presenting
the same characters as  in other parts of the body.   They are
generally solid bodies, of firm consistence, and whitish colour,
varying from the size of a pin head, or  a small pea,  to that of
a walnut or a small egg.  We find them in every part of the
brain, either embedded in its substance, lying on the surface
or attached  to the membranes.   When they have attained a
considerable size, they present when cut into, the usual whitish-
coloured or cheesy matter generally enclosed in  a cyst; and 
TUBERCULAR DISEASE  OF THE BRAIN.       135
in the fatal cases, we find them more or less approaching to a
softened state, or partial unhealthy suppuration.   They occur
in persons and in families, in whom a tendency to tubercular
disease has otherwise manifested itself; and they are very of-
ten combined with tubercular disease in other organs.   This
is remarkably exemplified  in the first of the following  cases,
in which all the three great cavities  were at once extensively
affected.
  The symptoms accompanying tubercular disease of the brain,
in its early stages, are often exceedingly obscure and variable ;
perhaps little more than a tendency to headach, which assumes
no formidable character, or sometimes assumes the appearance
of what has been called the periodical headach, or the sick head-
ach.  The symptoms may go on for a long time in this man-
ner without exciting any alarm, until the disease suddenly as-
sumes a more active character and is speedily fatal.   This
termination seems in general to be connected with inflamma-
tory action of the cerebral substance ; and we find upon dis-
section, either extensive effusion or  extensive ramollissement
of that part of the  brain  in  which the principal tubercular
masses are situated.  In other cases, we have every proof that
masses of a very large size had existed without producing any
symptoms, until an attack took place which went through the
usual course of hydrocephalus.   Examples of tubercular dis-
ease in the brain  have already occurred in connexion  with
some of the diseases formerly referred to.  I add the  follow-
ing cases as illustrating the affection in its more pure and sim-
ple form.

   Case LXXXI.—A young lady aged 15, fell into bad health
in the beginning of the year  1822,  complaining at that  time
chiefly of pain in the bowels, with bad appetite; and she be-
came languid and sallow.   She went through the usual course
of treatment for such affections, under the care of Mr. William
 Wood, with apparent benefit; but after some time she began to
have cough, with uneasiness in the chest, and these symptoms
then became the object of attention.   Some time after this she
began to complain of headach, for which she was treated with
topical bleeding and blistering, and again experienced relief.
 In this manner she went on for several weeks  more, com-
plaining sometimes of her belly, sometimes of her breast, and
sometimes of her head.   The pain was never severe in any of
these  situations, but she  was seldom  without  uneasiness in 
136
TUBERCULAR DISEASE
one or other of them.   Her bowels at first had  been rather
loose, but afterwards were natural, or easily kept open by mild
medicines.  When  I saw her along  with Mr. Wood, in the
beginning of March, she was considerably reduced in flesh
and strength;  she was  confined to the  house, but able to be
up and  dressed during  the day.  She  had a small frequent
pulse, little appetite, some cough, and occasional uneasiness
in the chest; there was  frequent pain in the head, and febrile
flushings took place in the  evening.   She now made little
complaint of her  bowels, which  were easily kept open, and
the stools were natural.    It was evident that there was disease
in all the three cavities,  though it was  doubtful  in which  of
them it was  to assume the fatal character, until  the 15th March,
when the headach became more severe, so as to confine  her
to bed.   It  then  went  on in  the usual manner with dilated
pupil, squinting and^coma ; and she died on the 20th.
  Inspection.—The ventricles of the brain were distended with
fluid.   In the substance of the right hemisphere,  there was a
tubercular mass  of considerable size,  partly softened; and
there were several smaller masses of the same kind in the sub-
stance of the cerebellum.   The lungs were studded throughout
with innumerable  small tubercles, all in the solid  state.   The
abdomen presented  a most  extensive  mass  of  disease,  the
whole of the intestines being  agglutinated together by adhe-
sion ;  and the mass thus formed likewise adhered extensively
to the parietes of  the abdomen and to the omentum.

  Case LXXXII.—A young lady aged 18, had enjoyed good
health, except from  a scrofulous sore on the left arm, till about
the middle of February, 1822, when  she  began  to complain
of headach.   There was fever, with  oppression  and  loaded
tongue;  and the headach became so  severe, that Sir George
Ballingall was induced to treat her in the most active manner
by general and topical   bloodletting, &c.   When I  saw  her
along with him, about the end of the  first week of her illness,
she had still much headach, with a look of great oppression,
but was quite sensible.   The  pain was chiefly referred to  the
back of the head and neck, and was much aggravated by mo-
tion, even by being raised up in bed in the most  gentle man-
ner.   The tongue was covered with a dense white crust, and
the pulse was frequent and rather weak.   After farther topical
bleeding, purgatives, &c, there was a gradual improvement;
and, at the end of the second week, the tongue was clean, and 
OF THE BRAIN.
137
the look of oppression and stupor was gone.   But though her
general aspect was now greatly improved, she was not free
from uneasiness in the head, and she did not recover strength.
After an interval of partial relief, the headach again increased,
with a  look of much languor and oppression.  After continu-
ing a few days in this  state, she died rather  suddenly.   At
the morning visit of the day in which she died, she appeared
sensible to every impression, and answered questions distinct-
ly when roused.   Her death took place about five weeks after
the original attack.
   Inspection.—There was considerable effusion in the ventri-
cles of the brain.   In the substance of the right  hemisphere,
there was a soft tubercular mass of large size ; and there was
considerable ramollissement of the cerebral substance surround-
ing it.   There were two smaller tumors of  the same kind in
the cerebellum.  There were numerous tubercles in the lungs
not suppurated.   There was much disease of the uterus  and
ovaria, which were considerably enlarged; and the Fallopian
tubes, in particular, were very  much enlarged, and distended
with a  soft  cheesy matter of a yellow colour.

   In this case it seems probable that the  attack of the middle
of February was continued  fever, and that the disease in the
brain was thereby excited into action and hurried on to a fa-
tal termination.

   Case LXXXIII.—A boy aged 9, in January, 1821, began
to complain of headach.   It was  usually accompanied  with
pain about  the umbilicus, and  attacked him daily, the attack
commonly continuing from  half an  hour to two or three hours.
The headach at first came on about two o'clock in the morn-
ing, and generally continued about one hour, but the  period
of its duration was gradually extended to three or four hours.
The period of attack also gradually became  later, until it  ad-
vanced progressively to five in the afternoon; it did not  be-
come later than this.  The attack usually occurred every day,
and generally went off with vomiting.   During the attack, the
pain was most violent, so as to incapacitate him  from any ex-
ertion ; but during the rest of the day, he was lively and play-
ful, and made no complaint.   He went on in  this manner for
six months.  In the beginning of  July, he was  seized with
fever and pain in the bowels, and was confined to bed.  The
headach now became constant, and there was frequent vomit-
                            18 
138               TUBERCULAR DISEASE
ing.   After some days the vomiting ceased, but he continued
to have fever, with considerable permanent headach ; and  at
the end of a fortnight from the commencement of the febrile
attack, he died rather  suddenly without coma or any affection
of the senses.
   Inspection.—The brain was quite healthy, and there was no
effusion in the ventricles.  In the left lobe of the cerebellum,
there were two tubercular masses, the size of large hazel nuts ;
and there was another similar tumor betwixt the  two lobes;
they were round and firm, and internally presented a yellowish
cheesy consistence.  In the thorax, there was extensive adhe-
sion, but the substance of the lungs was tolerably  healthy.
In the abdomen  there  were slight adhesions of the viscera.

   Case LXXXIV.—A  child aged 3 years, of a family who
had suffered much from  various forms of chronic disease, had
been for some months affected with a moveable  swelling on
the arm,  of a strumous character, and was  liable to discharge
of matter from the left ear.  He was otherwise in good health
until the beginning of April, 1827, when he was observed  to
have a peculiar unsteadiness in his limbs in walking, and a pe-
culiar want of control  over his arms in attempting to  lay hold
of any object.   From  this time he showed a disinclination  to
walk, but no other symptom was taken notice of till the mid-
dle of May, when he  complained of pain in the back  of his
head, especially  in the left side behind the  ear.   He was now
confined to bed, and was fretful and feverish.   On the third
day from the commencement of these symptoms, he began  to
squint, and about the  same time  to be  affected  with  convul-
sive attacks, which generally occurred three or four times in a
day; they  affected at first the whole body, but afterwards
were confined to the right side, and were generally accompa-
nied by distortion of the eyes, and a degree of stupor, which
however was of  short  continuance; his pulse was generally
about  120.   He lived in this state for twelve days, and no
particular change of symptoms took place, except that a few
days before  death the  pupils* became dilated and insensible.
He appeared to  be comatose  only on the last day of his life,
having continued till that time to be  sensible to  every thing,
and to take his food readily.   I saw him along with Mr. Mac-
farlane, and all the usual remedies were employed without re-
lief.
   Inspection.—There  was  considerable effusion in the ven- 
OF THE BRAIN.
139
tricles; the brain was in other respects healthy.   In the pos-
terior part of the cerebellum there were two tubercles the size
of large walnuts.   They were  situated one in each lobe, and
completely imbedded in the substance of the cerebellum. Ex-
ternally they were  firm and of a yellow colour; internally they
showed the usual appearance of unhealthy suppuration; there
was extensive ramollissement in the substance of the cerebel-
lum ;  and  there was extensive effusion in  the spinal canal,
both betwixt the bones  and the dura  mater of the cord, and
betwixt that membrane and the pia mater.  The substance of
the cord seemed  much softer  than natural, especially at the
upper part, where, in consequence of its softness, it had given
way in opening the spine.
   On the subject of tubercular disease  in the cerebellum, I
shall  only add the following remarkable case, showing in  a
very striking manner, the remissions which take place in the
symptoms in diseases of this class, and the periodical charac-
ter which they sometimes assume.

   Case LXXXV.—A  gentleman aged 34, in the year 1825,
first began to be affected with occasional attacks of headach,
which were usually accompanied  by vertigo and dimness of
sight.  In  1827, the pain became more severe, and  was dis-
tinctly referred to the occiput and  superior part of the  neck.
He had generally remission of it through the day, and  aggra-
vations in the evening.   In the spring of 1828, the symptoms
increased in severity, but he received considerable relief from
blistering.  In the summer he went to the country, where his
general health was much improved, and his headach  greatly
mitigated.  He continued in this improved state till May, 1829,
when  the attacks of headach were again aggravated, accom-
panied by giddiness, and  on one occasion  he fell from his
chair.  In  October of the same year, he began to be affected
by a most distressing  sensation of throbbing referred  to the
back part of the head;  and he  was also affected  with  vomit-
ing, which Continued without intermission for three  weeks.
The paroxysms of headach were now aggravated to an intense
degree of severity.   They occurred chiefly in the evening, from
six" o'clock till midnight,—but  also at  other times  of the day.
During the more severe attacks, his face was flushed,—the
vessels on the temples were remarkably distended, and he lay
in  a  state  nearly of unconsciousness, unable  to  speak, and
with his  hands and arms spasmodically contracted.  He still 
140
TUBERCULAR DISEASE
had occasional  vomiting and intense acidity of the stomach,
and  several times  complained of  double vision.   The  pulse
was generally natural.   His situation was now considered  as
nearly hopeless ; and no relief was obtained from any reme-
dies ;  but after five or six weeks of intense suffering, the symp-
toms gradually remitted, and during several weeks in Decem-
ber and January, he continued almost free from headach;  he
was able to walk out, and his general health was greatly im-
proved.   In  February, 1830, the  symptoms  again increased,
but the pain was now chiefly complained of  above the  eyes;
the remissions also were more complete, and, upon the whole,
his sufferings were less severe than  during the attack in Novem-
ber.   In March, his  complaints again  subsided, and he was
able to take a good deal of exercise  in the open air, and to attend
a good deal to his business.  He  had still  occasional attacks
of headach, but they were not severe, and his  condition was
considered as much more  favourable than it had been for a
long time.   In the middle of April, the paroxyms of headach
became more severe, but by no means in the degree  in which
they had occurred on former occasions.  He was not confined;
and no degree of apprehension was excited until the  24th,
when, in one of those paroxysms, he suddenly  expired.
   Inspection.—The  ventricles of the  brain contained from
three  to four  ounces of limpid fluid ; but the surrounding parts
were  entirely healthy.  Imbedded in the substance of the left
lobe of the cerebellum there was a tubercular mass, the  shape ^
and size of a very small walnut.   Externally it was firm, and
presented the usual appearance of the scrofulous tubercle ; in-
ternally it was softened, with the  common  appearance of un-
healthy  scrofulous  suppuration.  The substance of  the cere-
bellum around it was entirely healthy.   No  other appearance
of disease was discovered in the head ; and the other viscera
were  sound.

   The following case, for which I am indebted to Dr. Combe,
of Leith, while it affords a good example of tubercular disease
of the brain, is interesting from the singular coincidence of the
two forms of paralysis,  on the opposite  sides of the face ;  the
one connected with the division of the  portio dura, the  other
with the disease in the brain.

   Case LXXXVI.—A man aged 36, about a year before his
death, had a tumor extirpated from behind the  angle of the 
OF THE BRAIN.
141
jaw, on the left side, and immediately after the operation, pa-
ralysis took place in the left side of the face, in consequence
of which his mouth was distorted to the opposite  side in a
most extraordinary  degree.  About six months after this,  he
began  to complain  of  headach,  and  giddiness, which often
gave him the appearance of intoxication, and after some time
these symptoms were followed by impaired vision, occasional
strabismus, and a considerable degree of deafness ; and at last
by drowsiness, coma,  convulsions,  and  death.   As these
symptoms advanced, he became  affected with numbness, and
loss of power of the right side of the face, which  increased
very gradually.  During the increase of this, the distortion of
his mouth gradually diminished,  and for some time before his
death  his countenance had become  entirely symmetrical.—
Both sides of his face  were now entirely paralytic, but with
this difference, that  on  the right side the feeling was also lost,
while on the left the feeling was  entire.
  Inspection.—In the  centre of  the middle lobe of the right
hemisphere of the brain, there  was a  tubercle about an inch
long, and three-fourths of an  inch  in  breadth.  At  its lower
part it  was attached to the cerebral substance, but the rest of
it was  detached, being surrounded with dark-coloured pus.  In
the vicinity, there was  increased  vascularity with softening of
the cerebral substance.

  I shall only add on this subject  one remarkable case of a
tubercular mass of very great size attached to the falx, which
must have existed  for a long time  without producing any
symptoms.

  Case  LXXXVII.—A boy aged  7, had been for more than
a year  affected by scrofulous sores, and during that time had
been in a declining  state of health, without any local internal
symptom, till six weeks before his death, when he began to
complain of pain in the forehead, and considerable uneasiness
in the  abdomen.  His  pulse was natural, but his appetite was
bad, his tongue foul, and his sleep disturbed.   After the usual
treatment, the pain  in the belly was removed, and the head-
ach was  much relieved, so that for a fortnight he made little
complaint.   The headach  then returned with much severity,
and, without any other change in  the symptoms, he became
gradually comatose, and died after three  days of  profound
coma. 
142
tubercular disease
  Inspection.—There was much effusion in the ventricles of
the brain, and considerable ramollissement of the cerebral sub-
stance in several places.  A large  firm tumor adhered to the
middle of the falx on the right side. It was nearly five inches
in circumference at the broadest part,  and about an Inch and
a half in thickness.   Internally, it was of a yellowish-white or
ash-colour, and of a consistence resembling that of coagulated
albumen.   It was imbedded in the substance of the right he-
misphere, where it  had  formed  a depression. for itself, but
without any adhesion to the  arachnoid of the part.   There
were two smaller tumors the size  of  large nuts,  and of the
same appearance, also attached to the falx,—the  one at  its
posterior, and the other at its anterior extremity, both on the
right side.   Another tumor of the same kind was imbedded in
the anterior lobe of  the left; hemisphere, and was attached by
a slender filiament to the pia mater.

  There is reason to believe that the deposition of tubercular
matter in the brain,  as in other parts of the body, is often the
result of inflammatory action of a  low scrofulous  character;
that it may at first be excited  by injuries or  other causes of
inflammation; and  that it  may then  advance gradually in a
slow, insidious manner.

  Case LXXXVIIL—A boy aged 8, in June, 1821, fell from
a height and received an injury on the head, wThich was fol-
lowed by considerable stupor.   He was relieved for a time by
the usual remedies ; and though he was never altogether well,
no remarkable symptom  occurred till  the middle of October,
when he complained of a sense of weight in the head, follow-
ed by some stupor, with slight paralysis of the right arm and
leg.   He continued in  this state without any farther change,
till the 2d  March, 1822, when he was  seized with  severe
headach, fever, restlessness, and dilated pupil.  After partial
relief, by the usual  remedies, he  sunk gradually into coma,
and died on the 17th.
  Inspection.—The  ventricles of  the  brain  contained  about
eight ounces of fluid.   In the lower part of the posterior lobe
of the right hemisphere, there was a firm tumor the size of an
almond.  The right lobe of the cerebellum  was reduced to
nearly a purulent consistence.  Below it, and immediately be-
hind the petrous portion of the temporal bone, there was a tu-
mor the size of a hen's egg, externally of a firm consistence, 
OF THE BRAIN.
143
but internally approaching to suppuration.   It adhered firmly
to the dura mater, which was  much thickened at the place of
the adhesion.
   Case LXXXIX.—A boy aged 7, (for whose case I am in-
debted to the late Dr. Gregory,) in the beginning of the year
1811, received a severe injury of the forehead and nose by a
fall, his nose being nearly flattened by it.   From this time, he
complained of headach, and, after two or three months, be-
came near-sighted.   Soon after, his sight became indistinct,
and after four or five months more, this was followed by blind-
ness.   About this time he began to be epileptic, and to be af-
fected with weakness of the lower extremities, which gradual-
ly increased to perfect paraplegia.   He died in  April, 1812,
after coma of three days, his intellect having continued entire
till that time.
   Inspection.—A  firm white  flat tumor,  the size  of  a large
bean,  lay over the junction of the optic nerves.   The ventri-
cles contained twelve ounces of clear fluid.   The left  lobe of
the cerebellum was  much  indurated ;  and the right lobe  was
reduced to  a mass of unhealthy scrofulous suppuration.

   Nearly analogous to tubercular disease in-the brain, appear
to be those cases  in which albuminous matter in a pure state
is deposited in cysts in various parts of the brain, or under the
membranes. The  symptoms connected with some of these are
very remarkable.

   Case XC.—A  woman aged about  50, had been ill for a
year or more  before her death, during the greater part of which
time she had been confined to bed, or able to be out of it only
a part of the  day.  She was  affected with violent paroxysms
of headach, which usually attacked  her in the night or about
four o'clock in the morning,  and generally continued  for two
or three hours, when it  subsided, and left her tolerably easy
till the same time  the following night.   Sometimes the attack
was of shorter duration, going off in a quarter or half an hour.
During the paroxysm the pain was  most  intense, and  was
sometimes  accompanied or succeeded by delirium, and some-
times by coma of short duration ;  on several occasions squint-
ing was observed.  Her death was  rather sudden ; she went
to bed at  night in her ordinary health,  and was seized with
her usual paroxysm, which went off about the common time ; 
144
TUBERCULAR DISEASE
but it returned a second and a  third time, and she died early
in the forenoon.,
   Inspection.—There was considerable effusion in the ventri-
cles of the brain, without any disease of  the substance.   Be-
tween the lobes of the cerebellum, at the upper part, there was
a firm white cyst containing upwards of an ounce of transpa-
rent albuminous matter of a pretty firm consistence, and in the
lower part of the cyst there was some coagulated blood mixed
with it.

   Case XCI.—A man aged 50, had been for some time af-
fected with cough and bloody expectoration.   In June, 1818,
he was seized with headach, and some confusion of thought,
which appeared chiefly in a tendency to misapply words.  The
pain, which was referred chiefly to the forehead,  increased in
severity,  and attacked him in violent paroxysms.   The sight
of his right eye was impaired,  and  soon after lost;  and his
speech became indistinct, and after some time inarticulate.—
Six weeks after the  commencement of these complaints, all
the symptoms were  increased.  Violent paroxysms of  pain
were excited by the least motion, and even by change of pos-
ture in bed.   He seldom attempted  to  speak}  but he  often
pressed his hand on his forehead,  and seemed  to have unea-
siness in  his right arm.  He had some squinting, with gene-
ral weakness and paleness,  and his intellect was evidently im-
paired.   He died in August in a  state of coma.   The pulse
had been usually natural, sometimes slow.
   Inspection.—In the substance of the left hemisphere of the
brain, towards the posterior part, there was a soft and vascu-
lar cyst, containing about two ounces of a thick colourless al-
buminous fluid, coagulable by heat,  and exactly resembling
the albumen of an egg.  The  cerebral  substance round the
cyst was  softened ; the brain in other respects was healthy.—
The ventricles contained a small quantity of serous fluid, and
had no communication with the cyst.

   Case XCII.—A child, aged at the time of his  death 3 1-2
years, died in May, 1823, after having been  for  nearly three
years  affected with almost constant convulsion.   The disease
began at the age of  eight months, and  at first assumed the
form of a singular convulsive starting of  the left arm and leg,
compared by an intelligent surgeon who saw him at the time,
to the motion which  is produced by the electric  shock.   By 
OF THE BRAIN.
145
degrees this passed into more regular convulsion, which after-
wards affected the whole body.   It occurred generally five or
six times every day; occasionally there  were intervals of a
day or two, and at one time of two weeks ; but, after such in-
tervals^ the  disease  generally recurred with double severity.
For a year or more before death, the child had been in a state
of general palsy, except an occasional motion of the left hand.
He was in a state of perfect idiotism, and never attempted to
speak;  he swallowed food when it was put into his mouth ;
and occasionally  expressed his wants by peculiar cries, which
his mother came to  understand.   Notwithstanding the com-
plete want of voluntary power, the convulsive movements con-
tinued with  great severity, and all the long bones of the  ex-
tremities were twisted by them in a most singular manner.
   Inspection.—The bones were all very soft, and the long
bones of the extremities singularly twisted ; the head was of
a natural size, and the anterior fontanelle was open.   The
left hemisphere of the brain, over rather more than its anterior
half, was remarkably depressed by a mass of pellucid albumi-
nous matter, which  was lodged under the  arachnoid; it re-
sembled in appearance the albumen of an egg, but was much
firmer, so that pieces of it could  be separated from the mass
and lifted up.  Parts of the mass being  thrown into  boiling
water became immediately opaque and coagulated.   The brain
in other respects was healthy.

   In these cases the fluid  contained in the cysts was of an air
buminous character.   But it may also  be found serous even in
cases of very long standing.  A very remarkable case is men-
tioned by Andral.  The patient was affected, at the age of  8
years, with palsy of the left side,  which continued till puberty,
and then gradually disappeared, leaving the limbs which had
been affected, however, weaker than those of the other side,
and much smaller in size.   He lived in this state  to the  age
of 72, and then died exhausted, without any symptoms in the
head, or palsy.   About the middle of the right hemisphere,
there was found a cyst, formed in  the sub-arachnoid cellular
texture, full  of a  serous fluid, and the  size of a small apple,—
(" pomme d'api.")

  I conclude this part of the subject  with  the following re-
markable case, showing the most extensive destruction of the
substance of the brain that has ever occurred to me.  It seems
                           19 
146
TUBERCULAR DISEASE
 to have  been originally a tubercular mass  mixed with  some
 masses of an albuminous character, and at last terminating by
 most extensive ramollissement.   When we consider the extent
 of the  disease,  and the state of health of  the  patient a few
 hours before death, it is probably almost unique in the history
 of diseases of the brain, and shows us in a  very striking man-1
 ner the imperfectibn of our knowledge in regard to the symp-
 toms arising from cerebral disease.

   Case XCI1I.—A young lady who, between her  14th and
 17th years,  had  suffered considerably from chronic  ophthal-
 mia, was attacked in her 18th year with paralysis of the face.
 The mouth was  twisted to the right side ;  the  orbicularis  of
 the  left  eye was affected,  so that  the eye could not be  shut
 without a great effort; the  sight of that  eye Was much impair-
 ed, and there was numbness of the whole left side of the face;
 the pulse was natural;  The affection had begun with pain re-
 ferred to the left ear.   She was bled generally and  topically,
 and freely purged, and the affection disappeared in six or eight
 days.   Some time after, she had a second attack of the  same
 kind, which  also subsided in the  same manner.  After this
 she became  liable to attacks df giddiness, accompanied by in-
 distinct  vision, and followed by vomiting.   These attacks
 were of frequent occurrence, but did not  in general   continue
 above a day or two, and in the intervals she was in perfect
 health.   These symptoms went on  for about a year.   In her
 19th year, while she was one day  sitting at dinner,  she  sud-
 denly fell from her  chair in a state of complete insensibility,
 with general muscular contraction or rather  rigidity,  but with-
 out convulsion;  and in this state she remained for nearly two
 hours;  This occurred in the month of  June 1822, and  there
 was  no recurrence of the attack till December following, when
 she had one exactly similar.  A third took  place in  February
 1823 ; and a fourth in June of the same  year.  From the first
occurrence of these paroxysms, the attacks of giddiness became
more distressing, and were then for the first time accompanied
by headach,  which was chiefly referred to the left temple  and
the left ear;  and the attacks were often  followed by thin wa-
tery discharges from the ear.  After the fourth  paroxysm of
the comatose affection, she  began to have indistinctness of vi-
sion.   At this period  she  Used  sea-bathing, by which the
headach was increased, and the  indistinctness of vision pass-
ed into a considerable degree of amaurosis.   For the latter af- 
OF THE BRAIN.
147
fection, an emetic was now recommended to her, the opera-
tion of which was immediately followed by a violent attack of
the paroxysm of insensibility, and these continued to recur at
.short intervals to the time of her death.   In regard to the pe-
riod of their occurrence, the account of her friends was, that
for a fortnight they attacked her generally every day, and for
the  next  fortnight she was entirely free from them.   They
.continued  to exhibit  nearly the same characters as formerly
described, namely, insensibility, with muscular  rigidity; and
there never was any appearance of convulsion, except in  one
instance, during the whole course of the disease.  The attack
generally continued from half an hour to an hour; and, except
the imperfection of vision, her  general health  was so  good,
that she was married  in February 1824, which was about two
months before her .death.   At -this time she  first came  under
-the care of my friend, Dr. Ross, to whom I am indebted for
the preceding history; and the leading symptoms then were,
frequent recurrence of the paroxysms of insensibility, with vi-
olent headach, accompanied by giddiness and sickness.  1 here
was a  great degree of amaurosis, but  the pulse was .natural,
and her health in other respects good.  Under the use of ex-
tract of stramonium, the paroxysms were now suspended, the
vision was very much improved, and her general health  and
spirits were such, that the evening before her death was spent
 cheerfully with a party in the house of a  friend.  She return-
 ed home  about eleven o'clock at night,  and went to bed ap-
 parently in her usual  health.    About eight o'clock in the fol-
 lowing morning, she  was found in a state of insensibility with
 rigidity of the body; she was supposed  by her friendsto be
 in°one of  her usual  attacks, but when she was  seen by Dr.
 Ross,  a short time after, he found that she was  dead.  I was
 present at the examination of the body.
   Inspection.— The  brain externally  appeared healthy, but
 when  a thin section  was  cut from the upper part of the left
 hemisphere, a cavity was exposed, through which a probe
 passed in every direction  without any resistance, through near-
 ly the whole  extent  of the hemisphere.   This, upon  farther
 examination, was found  to arise from the whole  hemisphere
 being in  such a remarkable state of decomposition or softening,
 that it formed one great  cyst, full  of soft pultaceous matter,
 inclosed  in a very thin covering, formed by the healthy cere-
 bral matter on the surface.   The healthy portion forming this
 covering, in many places did not exceed a quarter of an  inch 
148    DISEASES  OF  THE BONES OF THE  CRANIUM.

in thickness ;  and at  the thickest parts, which were on the
upper surface of the brain, did not exceed  one-half or three-
fourths  of an  inch.   The contained matter was  a thin soft
pulp, mixed with  portions of a pellucid albuminous substance,
which coagulated  when thrown into boiling water.  This mat-
ter was  chiefly in  irregular masses, but there were some firmer
portions of it which could be separated in the form of distinct
round nodules, resembling hydatids.  On examination, how-
ever, they were found not to be hydatids, but uniform masses
of the albuminous matter in a more concrete state.   On the
external part of the hemisphere, lying over the petrous por-
tion of the temporal bone, there was a tumor the size of a pi-
geon's  egg, adhering firmly to the  inner surface of the dura
mater.   Externally, it was irregular as if formed of a conge-
ries of smaller tumors;  internally, it was composed  partly of
a reddish soft fleshed-coloured matter, and partly of a semipel-
lucid albuminous  substance, in nodules of various degrees  of
firmness.  When  thrown into boiling water, the whole mass
assumed a  uniform opaque white colour,  and  a hard cheesy
consistence.  The left ventricle was entire;  it contained a
small quantity of  serous fluid, and was separated from the dis-
eased mass by a very thin septum.   The  right  hemisphere
was  healthy, except  on the inner part  of the anterior lobe,
which was considerably softened.   It appeared to every one
who witnessed the  dissection, that the left hemisphere had
been considerably enlarged, and the right diminished in the
same proportion,  the falx being sensibly pressed towards the
right side.   The optic nerves seemed softer than natural; the
cerebellum was healthy.
                      SECTION IT.

OF CERTAIN AFFECTIONS OF  THE BONES OF  THE CRANIUM.

  I was led to make some  researches on this subject by the
following case.—

  CasE XCIV.—A woman aged 48, about a year before her
death, fell down  a stair, and received various injuries,  espe- 
       DISEASES OF  THE BONES OF THE CRANIUM.    149

cially one on the  head, which confined her to bed for  some
days.  From this time her  health  was  bad; she generally
complained of fixed pain of the head,  and had a very  disor-
dered state of the stomach and bowels.   She was able, howT-
ever, to attend to the ordinary duties of her family, till  about
three weeks before her death, when  she was  seized with fever
and  outrageous delirium.  These  symptoms subsided after a
bleeding; and next day, she had erysipelas of the face, which
went off in a few days.  She was then able to be out of bed,
but complained of a fixed and deep-seated  pain in the right
side of the head, a little above the ear, and there was discharge
of matter from the right ear.  She continued in this state, sit-
ting up part of every day, till three days before her death,
when she became comatose, with partial paralysis of the left
side, and frequent convulsive motions of  the right arm.  She
died on the third day  after the occurrence of these symptoms.
   Inspection.—The cranium was very easily opened, the bones
being remarkably soft.  On  raising the  skull cap, the inner
surface of the whole upper part of the cranium  exhibited a
singular state of disease.  The inner table seemed to be want-
ing through its whole  extent, and there appeared the rough,
irregular,  and cancellated structure  of  the central part of the
bone.  Betwixt this surface and the dura  mater, there was a
deposition of soft adventitous membrane of a  yellowish colour,
varying from one-twelfth to one-eighth of  an inch in thickness.
In raising the skullcap, this membrane, in some places, adher-
ed to the  dura mater, leaving exposed the irregular cancellated
structure of the bone ;  and in  other places, it  adhered to the
bone, depriving the dura mater of its natural  appearance. The
parts affected by this singular state  of disease were, the fron-
tal bone  above the orbitar plates, the whole of both parietal
bones, the squamous portion  of both temporal bones, and  ra-
ther more than the upper  half of the  occipital bone.   The
greatest erosion was on the parietal bones, where several por-
tions were very thin and transparent,  and a few points  were
perforated.   The external surface of the cranium was of a na-
tural appearance, except at the few points where the erosion
had perforated the bone by very small apertures.   In the low-
er part of the right hemisphere of the brain,  towards the pos-
terior  part, there was an  extensive abscess.   The  brain in
other respects was healthy.   On the  petrous portion  of  the
right temporal bone, the dura mater was of a dark colour, and
detached  from the bone; but the  bone was healthy. 
 150    DISEASES OF THE BONES OF  THE  CRANIUM.

   I find no case described by any writer exactly resembling
 this remarkable affection of the bone.  There was a complete
 destruction of nearly the whole inner  table of the  cranium;
 and in its place, a deposition of a soft adventitious membrane,
 by wThich the dura mater was  everywhere agglutinated to the
 diseased bony surface.  This disease must have been going
 on for a considerable time; the abscess of the brain was pro-
 bably recent, and the immediate cause of death.  The patient
 was a respectable married woman, and there seemed no ground
 for suspecting a syphilitic taint.  Such a disease therefore  is
 probably to be considered as the result of a slow inflammatory
 action affecting the bone, and gradually destroying it by caries.
 Such a disease may originate in an injury, or may commence
 without any obvious cause.   It affects most commonly the ex-
ternal table of the skull, though it may likewise affect the in-
 ternal ; but I have seen no case described by any writer  in
 which it was entirely confined to the internal table.   A lady,
 mentioned by Mr. Howship,* at the age of 15, received a slight
 blow on the right side of the head, and for 30 years after, was
 liable to severe headach, which was  constantly referred  to
 that spot.   She then became drowsy, and her vision was im-
 paired, and at the age of 50 she died comatose.   At the seat
 of the original injury, the bone, to the extent of a crown piece,
 was so thin from absorption as to be almost transparent. The
 dura mater at this part was altogether removed, and the brain
 beneath was of a dark livid colour, and much indurated; and
 this disease extended through the whole  middle lobe.   In a
 case mentioned by Desault, death followed a blow on the head
 after a month:;  the bone was externally sound, and its cover-
 ings were healthy; but the internal table was blackened through
the whole extent  of one of the parietal bones ; the dura mater
 adhered to the bone as firmly as to the other parts of the cra-
 nium ; and there was suppuration on the  surface of the brain.
 This was probably an earlier  stage of that disease which oc-
curred in  Case XCIV.., and  in a more limited form  in Mr.
 Howship's case.
   A man aged 28, whose case is related by Mr. Wathen, was
 affected with a swelling the size of a pigeon's egg on the left
 parietal  bone.  It gave him no  pain, and continued  nearly
 stationary for a year and a half, when a similar tumor appear-
 ed on the  side of the osfrontis.  These swellings increased,,
*'Praeli«al Observations in Surgery and Mopbid Anatomy. 
        DISEASES OF THE BONES OF THE CRANIUM.     151

and after* several weeks were united, so that  they nearly co-
vered the left side of his head.   The swelling was  colourless
and without pain, and about this time he suffered some con-
vulsive attacks.  Caustic was applied to the posterior part of
the tumor, and, when the eschar separated, the integuments
were found  to be two inches in thickness;  and the bone be-
neath was extremely irregular, sending up sharp bony Spicu-
le into the tumor, some of which were an inch in length.  A
similar eschar being taken out from the anterior part showed
the same appearances.   Much thin  ichorous  matter was dis-
charged from the openings with some pus.  He had now fre-
quent pain and fever, with occasional convulsion and delirium;
but continued to go about, and could walk  many miles.  He
died gradually exhausted, but  retaining his faculties to the
last, two years and a half after the commencement of the com-
plaint.  On dissection, the whole left side of the cranium was
found perforated by numerous openings, between which there
were bony ridges, filaments, and  processes  of a  variety of
shapes; the sharper spiculae piercing the substance of the dis-
eased integuments. t The two largest perforations correspond-
ed to the seats of the two original tumors, and corresponding
to these there were  two small abscesses in the brain.   The
inner surface of the bone was diseased in the same  manner as
the outer, and the dura mater was  connected to it by a soft
fungus,  which arose from every part of the diseased bone.*
Morgagni mentions extensive  caries of the back part of the
cranium, with remarkable thickening of the dura mater,  which
originated in a blow, and proved fatal after six years ; and in
a young man who  died epileptic, after having suffered long
from intense headach, Zacchias found the inner table of the
occipital bone carious to a small extent, the other table-being
sound.  A  man, mentioned by Dr.  Clossy, became epileptic
after a blow on the head, and the fits returned several tjmes a
day for three years.   A fulness was perceived at the seat of
the injury, which, being exposed by an incision, was found to
be an elevation of the bone, namely, a part of the left parietal.
At this place the trephine was applied, and the bone on per-
forating it was found " cellulous and spungy, with  pus  in the
midst."  The man died comatose a few days after  the opera-
tion, and on inspection, there was found a circular asperity on
the inner surface of the bone about the size of a crown  piece,
* Medical Observations and Enquiries, vol. v. 
152     DISEASES OF THE BONES OF THE CRANIUM.

with several small abscesses in  the  membrane the  size  of
peas.*

  The cases  now referred to may be considered as examples
of an uncommon modification of  the disease of the bones of
the head, in which it is principally confined to the inner table.
The more common modification  of  it is that which occurs in
the outer table, or which affects the whole depth of the bone;
and some remarkable phenomena are connected with the his-
tory of the disease.  It appears to be the result of  a peculiar
low inflammatory action, which may arise from injuries often
very slight; or may commence without any obvious cause.
Its progress is often extremely slow; but when it has been
excited, it is impossible to conjecture  how far it may extend.
It may terminate by exfoliation of the front of the outer table,
or may affect the whole depth of the bone; and it may extend
to the dura mater and brain, and then be speedily fatal.   A
man, mentioned by Mr. O'Halloran, was seized, without any
injury, with a pain in the upper part of the os frontis, which
increased in violence with throbbing, so  as  to  unfit him for
his  employment.  After nearly four months, an abscess was
formed on the part, which burst; the bone was  found carious,
and perforated by an opening, through which the dura mater
could be  seen  covered with pus, and by this opening matter
was discharged at each dressing to  the  amount of a table
spoonful.   The piece of bone became loose,  and separated in
ten days; another piece, which was also carious, was separat-
ed in  another week, and in a fortnight from  this  time  the
wound was healed.f   This may be considered  as an example
of the  idiopathic form of the disease.   The inflammatory ac-
tion  probably began in the pericranium, and  afterwards af-
fected the bone.  The disease arises more commonly from in-
juries, and is often remarkably slow in its progress.   A man,
mentioned by the writer now referred to, received a blow on
the head with a cudgel, which left some heaviness and head-
ach, but without any urgent symptom, until many months af-
ter, when  a tumor formed on the part, and attained the size of
an apple.  It was opened, and under it there  was  found  a
circular aperture in the cranium the size of a half crown,  ex-
posing the dura  mater, which was covered with pus.  After
some  time, a  fungus arose  from it;  and after this  had been
■*Clossy's Observations on some of the Diseases of the Human Hody, p. 17.
t O'Halloran on Injuries of the Head, p. 58. 
        DISEASES OF THE BONES OF  THE CRANIUM.    153

destroyed by alum, the sore healed. A boy aged 7, mentioned
by Sir T. Cullum, fell with his head in the fire, it was sup-
posed from a fit, and was much burned before he was observ-
ed.   The consequence was an extensive  eschar, which  did
not separate for a very long time.  It then left the  bone quite
bare, and after three months more a separation of bon,e took
place in one piece, consisting of the whole of one parietal bone,
part of the other parietal, and part of the occipital.   Granula-
tions springing from the dura mater then presented themselves,
and  in six months  the sore was healed, except a  part about
the size of the mouth of a small tea-cup ; the boy being other-
wise in  perfect health.  Between five and six years  after, there
was  still a sore the   size of a  crown-piece, which discharged
considerably; and at that time,  "very little ossification  had
been produced towards the reparation of the injury."

   A remarkable circumstance in the  history of disease of the'
bone is, that  when it has once been  excited, it is not  always
confined to the part which was the seat of the injury, but may
spread gradually and extensively over other parts of the crani-
um.   A lady, mentioned by Mr. Norris, after a fall which pro-
duced at the time no alarming symptoms, was affected  with
pain in  the head.   It generally fixed with greatest  severity in
the os frontis, which had been the seat of the injury; and, on
that place,  a tumor formed, which  was opened more than
three months after the fall, when the bone was found carious.
The trephine  was then  applied, under the belief that  matter
might be lodged within, but none was found;  the disease was
confined to the bone, the dura mater being healthy.  A simi-
lar tumor soon after formed on the occiput, under which also
the bone was found carious; after  some time it exfoliated,  a
piece being thrown off the size of a sixpence, and the wound
healed.   In this manner tumor after tumor formed on various
parts of the head, and went through  the same course.  For
several months pieces of the outer table only were thrown off;
afterwards the whole depth of the bone was separated, at each
time exposing the dura mater; and from this period the sores
in the integuments did not heal.   She died nine months after
the commencement of the exfoliations ;  and on dissection por-
tions of the skull were entirely wanting, consisting, as far as
can be judged from the engraving,  of the upper half of the oc-
cipital bone, more than one-third of both parietal bones, and
a considerable portion of both temporal bones.  There was
                         20 
154    DISEASES OF  THE  BONES  OF THE CRANIUM.

not in this case the slightest suspicion of syphilis.*  A woman,
mentioned by Saviard, who was received into the Hotel Dieu,
in consequence of an injury of the head from a  fall, suffered
successive exfoliations of both tables of the cranium, to such
an extent, that the pieces, when put together, resembled the
skullcap as it is  sawn off in dissection.   This process occupi-
ed two years, at the end of which she was dismissed in  good
health, but with  the upper part of  the brain covered only by
integuments.  Hildanus relates the case of a man, on whose
cranium a number  of tumors formed, from  which pieces  of
bones were discharged, at each time exposing the dura mater.
The  sores had healed, and the man was alive at the time when
the account  was written ; but affected with paraplegia.  Simi-
lar cases are related by Portal; in two that were under his
own care, and in which he had no reason to suspect any sy-
philitic  taint, the disease was arrested  by mercury and anti-
scorbutics.
   Another peculiarity in the history of these affections is the
slowness with which the bone falls into disease, and the length
of time  during which a disease, of  small  extent, may exist,
producing urgent symptoms,  but making very little progress.
A lady, mentioned by M. Marechal, after a slight blow  on the
head, suffered constant pain in the part, often aggravated into
violent paroxysms, which the most active treatment had failed
to remove.  After severe suffering for several years, an inci-
sion was made,  when  a small  portion of the bone was found
carious.  This portion was removed by the trephine, and  the
patient  got well.  The disease in  this case was  probably su-
perficial, and it  is likely that  simply exposing the bone, and
promoting its exfoliation, might have answered as well as this
formidable operation.  In other cases of this kind, the disease
is at first confined to the inner table, from which it may, after
a long interval,  extend inwards, terminating by fatal disease
in the brain :  some examples of this have already been  refer-
red to.   In other cases, again, it appears that the disease may
be first external, arid afterwards, leaving its original seat, ex-
tend to the internal parts.  A boy, mentioned by Mr. Howship,
received at  school a blow on the head with  a ruler.  It was
followed by a small sore which continued to  discharge matter
for six years.   It  then healed, and  soon after his sight was
impaired, and he became epileptic.   The trephine was  ap-
* Transactions of the Medical Society of London, vol. i. 
       DISEASES OF THE BONES OF  THE  CRANIUM.    155

plied at the seat of the injury without relief; he died on the
third day after the operation.  The bone and dura mater were
sound, but the pia mater under the seat of the injury had evi-
dently  suffered from  chronic inflammation, and  the brain
was much indurated  through the whole extent of  the  middle
lobe.
  Many surgical writers teach us that in cases in which  the
bone becomes diseased after wounds and injuries of the head,
it is the separation of the pericranium  or dura mater that kills
the bone.   But every practical surgeon  must have seen nu-
merous cases in which the pericranium was separated without
any such consequence ;  and others, in  which the bone became
carious, though the pericranium had not been separated.   In
a case already quoted from Desault, in which death followed a
blow on  the  head  after a  month, the bone was  externally
sound and its covering healthy ; the internal table was black-
ened through the whole  extent of one  of the  parietal bones,
yet the dura mater adhered to this portion as firmly as to the
sound bone.   It appears to  be  the inflammatory action that
kills the bone, and this  action, we have  seen, may leave the
seat of the injury, and spread from one part to  another, until
its progress is arrested by the powers of the constitution, act-
ing in a manner which eludes our  observation, and which is
very little under our  control.  On this principle  it appears,
that there is in general very little encouragement for meddling
with such cases  by the  trephine.   If symptoms indicate the
formation of matter beneath the bone,  this must be evacuat-
ed ; but  perforations will remove only the danger from the
lodgment of matter, and their other effects on parts thus liable
to  inflammatory action are extremely ambiguous.  It is cer-
tain, that many cases of this kind  have proved fatal soon after
the application of the trephine, which had been going on for a
considerable time without exhibiting any unfavourable symp-
tom.  In a remarkable case  which has been reported to me
by an intelligent friend,  and which had this termination, the
inner table of the skull was found  on inspection to be perfect-
ly sound.   The disease  was confined  to the external table,
which was found to a considerable extent completely separat-
ed from the internal,  being confined only  by the integuments.
The case had originated in a slight wound which  had fallen
into an ill-conditioned state, and the caries had been going on
for a considerable time.   Free incision of the integuments is
the only practice that can be required in such a case, and then 
156    DISEASES OF  THE  BONES  OF THE CRANIUM.

promoting the separation of the diseased portion of bone by the
usual means.
  Even in the ordinary cases, so familiar to practical surgeons,
in which the formation of matter  takes place  within the cra-
nium in consequence of external  injuries, it  is probable that
the  main object of attention ought to be the inflammatory ac-
tion which has been excited,  rather than  the  mere  changes
which are going on in the bone; and that the formation of
matter is to be considered not as an  effect of the disease of the
bone, but as a result of the inflammation  of parts from which
the  bone itself has also suffered.   Cases  are  related by Mor-
gagni and others, in  which,  after such injuries, matter was
formed between the cranium  and  the brain, without the least
appearance of disease in the bone. The communication of in-
flammatory action from the bone itself to the brain and its mem-
branes, is  strikingly illustrated by  two cases  related by De
Haen, in his remarks on the application of the actual cautery
to the cranium.   This remedy seems to have been at that time
very much employed in various affections of the head ;  and it
was performed by first turning back a portion of the integu-
ments, and then applying the cauterizing iron  to the surface
of the bone.  In the two cases referred to, namely, a boy of
12, and a young woman of 20, this  practice was employed on
account of amaurosis.  They both died with symptoms of ce-
rebral inflammation; the former  on the  fourth day, and the
latter on the fifth, after the operation.   On dissection,  exten-
sive inflammation of  the  membranes  was found, with form-
ation of matter;  and in one of the  cases, the disease had affect-
ed the substance of the brain.  The cases are interesting, as
showing the direct communication of inflammatory action from
the bone to the parts beneath, without contusion or any inju-
ry which could directly produce the death of the bone, for no
caries or destruction of the bone itself was observed in either
case.
  In the affections of the bone, which have been the subject
of the preceding observations, the piece of bone, which was
the seat of the disease, is in general eroded by caries through
its whole extent; but a very  remarkable  variety of the affec-
tion has been described by Professor Russel, in which the ul-
cerative or carious process advances in a  narrow line in a cir-
cuitous manner, so as to insulate a piece of bone of  some ex-
tent, which is afterwards thrown out.  The part thus separat-
ed is in some cases perfectly healthy,  and in others is more 
DISEASES OF THE BONES OF THE CRANIUM.    157
  dense than in the healthy state, being smooth and white like
  a piece of ivory, and without diploe.  In some of these cases,
  the disease took place after injuries, and in others without any
  apparent cause.*
    Another singular variety of the affection occurs, in wThich
  after an injury  of the head, a portion of the bone disappears
  by absorption without ulceration of the integuments.   A child
  aged nine months,  mentioned by Mr. Howship,  received an
  injury of the right parietal  bone from a fall.  There  was no
  wound,  and no urgent  symptom at the  time;  but  several
  weeks after the accident, the pulsation of the brain was dis-
  tinctly perceived  at the seat of the injury, and the child be-
  came paralytic  on  the left side.   At the  age of four years,
  when the account was written, she had recovered the use of
  the left side, which had been  improving  gradually,  and she
  was otherwise  in good health ; but there was still a conside-
  rable deficiency of  bone on the  right side of the head, and
  when she cried or  coughed, this part became tense and evi-
  dently swelled. A boy aged  14,  mentioned by Mr.  Wilmar,
  received a blow on the head,  which was immediately follow-
  ed by a soft tumor  about two inches in  diameter at the base.
  After this tumor had continued stationary for two months, it
  was opened by a free incision, but discharged only blood in a
  fluid state.   Under it  the bone was  found to be  completely
  wanting to an  extent exactly corresponding to the base of the
  tumor.  The wound healed favourably, f
    Many cases  have occurred in  which  tumors of  the dura
  mater have  occasioned absorbtion of a portion of the bone,
  and have appeared under  the  integuments.  A  remarkable
  case of this kind,  which I saw  along with Mr. Wishart,
„ has been described by him in  the  Edinburgh  Medical and
  Surgical Journal, (vol. xviii.  p. 393.)   Many others are on
  record, some of which present interesting  phenomena from
  complications of disease.   A girl aged 19, mentioned by Mr.
  Hill, was first  seized with numbness of the left hand, which
  gradually extended upwards along the arm, and  was accom-
  panied by vomiting and violent headach.  After two months, the
  whole left side became paralytic. After another month, a small
  tumor like a pea appeared  by the  side of the bregna, which
  being repeatedly opened with a lancet, discharged matter with
* Transactions of the Medico-Chirurgical Society of Edinburgh, vwl. L,
             t Wilmar's Cases on Surgery. 
158    DISEASES OF  THE BONES OF THE  CRANIUM.

some relief.  After seven months more, Mr. Hill found a small
opening in the left parietal bone about a quarter of an inch in
diameter, but which was plugged up by a hard substance from
within.   The trephine being applied at this place,  discovered
an abscess, which discharged four  ounces of matter, and a
small excrescence like a wart, which had completely plugged
up the opening in the bone, and had prevented the escape of
the matter.  There was much relief  after the discharge, but
protrusion of the brain took place, and she sunk gradually and
died in about two months, retaining  her faculties till the last
two days.  Much effusion was found in the ventricles of the
brain, and destruction of the  brain by suppuration about two
inches around the opening of the  skull.*   It seems probable
that in this singular case, the small warty excrescence on the
dura mater had produced absorption of the bone, and thus af-
forded a partial exit to the matter.   But many instances are
on record, in which, without  any cause  of  this kind, matter
formed within the cranium has found for itself an exit through
the bone ; some  examples of this have been already referred
to; I shall  only add another.    A  man, mentioned  by Dr.
M'Turk, in the Medical and Physical Journal for April, 1819,
was  affected with great derangement of the stomach and pain
in the back of his head,  which was much increased by mo-
tion.  His sight and hearing were impaired, especially during
the more severe  paroxysms of pain, when his sight was near-
ly lost.   He had continued in this state nearly a year, when a
tumor formed on the sagittal  suture, which being opened, dis-
charged matter freely ; and, on examining the wound, it ap-
peared that there was  an opening  in  the suture, and that the
matter came from within the cranium.  The wound healed
gradually in a few weeks, and from  that time he was free from
complaint.
                     SECTION III.

     OF CERTAIN AFFECTIONS  OF THE  PERICRANIUM.

  Some obscure affections of the head, accompanied by very
urgent symptoms, have been found to be connected with a
* Hill's Cases in Surgery, p. 130. 
DISEASES OF THE PERICRANIUM.
159
disease of the pericranium, the history of which presents some
very singular phenomena.  In the cases related by Sir Eve-
rard Home,* the symptoms in general were headach, with va-
rious uneasy feelings in the head, and a painful tenderness of
the scalp at a particular spot, with some degree of swelling or
thickening of the integuments  at the place.   In  one,  the
sight and hearing were considerably impaired, and in several
of the cases there were fits resemblingepilepsy. They were treat-
ed by dividing the integuments  and pericranium freely down
to the bone, and then dressing the wounds with lint, so as to
allow them to heal slowly with suppuration..  In making the
incision, the pericranium was found morbidly sensible, an I
considerably thickened; and in some of the cases, indurated,
approaching to the structure of cartilage.   This treatment was
in some of them followed by immediate and permanent relief;
in others, the patient  continued  liable to fits  or head-symp-
toms upon any excess.  In some of them, the incisions heal-
ed without any affection of the  bone  being  discovered ; in
others, a portion of the bone appeared white  and porous, or
honey-combed, and a limpid fluid  appeared to percolate through
it, which returned immediately as often as  it was wiped off.—
In one of these cases, the  porous piece of  bone exfoliated af-
ter the wound had been dressed  with  dry lint for six weeks ;
the  wound  then healed, and the cure was permanent.  In an-
other, after waiting eight weeks for the exfoliation, he touch-
ed it repeatedly with diluted nitric acid,  after which it exfo-
liated,  and the  cure was  permanent.   In  one fatal case, he
found  the  pericranium thickened into a  mass of  a  fibrous
bony texture, and, corresponding to this part internally, there
was  a similar thickening and induration of the dura mater.—
Most of these cases had been treated by long  courses of mer-
cury without benefit, in some of them with aggravation of the
symptoms.
  This affection seems to  correspond with the disease which
has been described by Mr. Crampton under the name of Pe-
riostitis.!   Among  his  cases, affecting various parts of the
body, there are two  remarkable examples  of it in  the head;
the  one acute, the other chronic.    In the former, a boy of 14,
the complaint began with  a  small angry tumor on  the right
side of the  nose, from which, after some days, a swelling ex-

  * Transactions of a Society for the Improvement of Medical and Surgical Know-
ledge, vol. iii.
  t Dublin Hospital Reports, vol. i. 
 160         DISEASES OF THE PERICRANIUM.

 tended along the right eyelids and  forehead, with considerable
 erysipelatous inflammation and fever.  On the ninth day, he
 became suddenly comatose, then convulsed, and died on the
 12th.  On  dissection, the pericranium  covering  the frontal
 bone was found red, thickened, and  detached  from the bone,
 much purulent  matter lying between them.   Internally the
 dura mater was  detached to an extent corresponding to the ex-
 ternal disease, and a greenish puriform fluid was effused be-
 tween it  and the bone.  The inner surface of  the dura mater
 was also covered with pus; the pia mater was red, very vas-
 cular, and covered with pus to the  extent of two inches on the
 part corresponding to the principal disease of the pericranium.
 The other case is that of a woman, aged  32, who was affect-
 ed with a tumor the size of a walnut over  the left parietal
 bone. It was soft, and elastic, and its origin  was ascribed to
 a blow six months before ;  there was an opening in the tumor,
 by which a  probe could  be passed down to the bone.  She
 had  intense pain in the left side of the head;  the right arm
 was wasted and paralytic, and the fingers were contracted ;
 both lower extremities were feeble ; her speech  was indis-
 tinct ; she had  vomiting,  and  frequent  epileptic  fits.   The
 tumor was divided freely down to the bone, and in doing so
 the pericranium  was found thickened, firm, fibrous, and mor-
 bidly sensible.   It formed the  principal  part  of the  tumor.
 The bone under the tumor was found rough and superficially
 carious.   A portion of it was removed by the trephine, and
 the  dura  mater  under it appeared very  vascular, and rather
thickened.  For six days after the operation  she had  fever,
 extensive erysipelas of the head,  delirium, and convulsions.
 Suppuration was then established, and  all these  symptoms
were relieved.   In the  course  of the  cure  a slough was
detached from the dura mater.   A fortnight after the operation
 she recovered the use of her arm, and was free from complaint.
  Tissot* seems to have met with'this disease, and to have
treated it upon the same plan, though he  gives a different ex-
planation of the effect  of his treatment.  He describes a case
in which  an intense pain was confined to a very small spot, at
the posterior angle of the right parietal bone.   It had resisted
for a long time all the most powerful remedies, venesection,
arteriotomy, issues, cupping, &c.   He cured it  immediately
 and permanently, by dividing the part down to the  bone, and
* Tissot Epist. Med. Var. 
             DISEASES OF  THE  PERICRANIUM.          161

 encouraging suppuration from the wound.   He  ascribes the
 cure to the division of the  subcutaneous nerves.  A woman,
 mentioned by Pouteau,  received a blow behind  the left  ear,
 from the immediate effects of which she soon recovered, but
 she continued  to be  affected with  pain in the spot for four
 years.   She then had convulsions, paralytic  affections, inarti-
 culate speech,  and a long train of the most urgent symptoms,
 which  sometimes resembled  mania, and sometimes tetanus.
 She had still pain  at the place of  the injury, where a small
 portion of the integument was red, and very gentle pressure
 upon the spot produced convulsion.  By a free incision down
 to the  bone, and allowing the wound to suppurate, all these
 complaints were removed.   A boy, mentioned by  the same
 writer, received an  injury on the crown  of the head by a fall,
 at the  age of  8 years.   A  painful feeling continued in the
 scalp at the place of the injury, and for 10 years he was liable
to intense headach, which  afterwards became so violent as
 often to occasion insensibility.  At the age of 24, there  was,
 at the upper part of the right parietal bone, the original seat
 of the injury and of the subsequent uneasiness, a spot slightly
 red and  a little swelled; the hair  upon it  was coarse, and
 stood out like  bristles, and pressure  upon the spot  produced
 intense pain.    The pain extended to the right eye, the vision
 of which was obscured when the pain was violent.   By a free
 division of the  parts every symptom was removed.   A similar
 case is related  by M.  Gervais, in  which the pain returned pe-
 riodically, and  the patient suffered  epileptic  fits daily.   A
 slight touch on the  affected part produced syncope.   On divi-
 ding the  integuments and pericranium, the surface of the bone
 was found  carious ; this soon exfoliated, and the patient re-
 covered perfectly.   Valsalva has taken notice of a remarkable
 thickening of  the  pericranium, in a case of long-continued
 headach  with  occasional delirium, and at  last convulsion.
 There was serous effusion in the  brain ;  but he says nothing
 of the state of the dura mater or the bone.
   This singular affection Sir E. Home considers as beginning
 in the dura mater.   Mr. Crampton thinks it commences in the
 pericranium.   The latter opinion seems to be the more proba-
 ble ; for, in some of Sir E.  Home's own cases, it was cured
 by simply dividing the  pericranium.   It appears,  however,
 that in the progress of the disease, both the bone and the dura
 mater are apt to be  affected.
                            21 
162          DISEASES  OF THE  PERICRANIUM.

  The following is the best example that has occurred to me
of this remarkable affection.

  Case XCV.—A servant girl aged about 20, fell backwards
with a child in her arms, and received the full force of the fall
upon the most  prominent part of the occipital  bone.   She
soon recovered  from the immediate effects  of the injury, but
continued to have pain in the part; and after several months,
was seized with paraplegia and retention of urine.  She was
now confined to bed for three or four months, after which she
recovered the use of her limbs in a tolerable degree, but the
retention of urine continued, and she came  to Edinburgh in
the beginning of 1828, which was more than a year after the
accident.   The paraplegia was now nearly  removed, but she
had  still retention of urine, requiring the constant use of the
catheter.   On the seat of the injury on the occipital bone, a
round portion, the size of a crown piece was  acutely tender,
and  very moderate pressure upon it produced complete insen-
sibility, which  continued a minute or two, and returned as
often as the pressure was repeated.  It had the appearance of
syncope, but the pulse was not affected.  In this state I  saw
her  along with Mr. Lizars, and it was agreed to make a free
crucial incision through the part, and to keep the wound open
by dressings so as to promote suppuration.   In doing so, the
pericranium was  found tender and somewhat thickened, but
the bone  was sound.  On the following day she passed her
urine freely, and she continued free from complaint as long as
the wound continued to discharge.   It healed at the end of a
fortnight, and the  retention  of urine  returned  immediately.
The incision was now repeated with the same result as before,
her urine being freely passed almost  immediately.  Various
means were then employed to promote a more complete sup-
puration from  the  wound, but  it healed after  two or  three
weeks, and the retention of urine returned as before, with con-
siderable tenderness in the affected  spot.  A third incision
was then made with the same  effect as before, and various
applications were made with the view of promoting exfoliation
of bone, as in Sir Edward Home's cases, but without success,
and the wound again healed after three or four weeks.   The
fits of insensibility on pressure now  returned, which had not
returned after the former  incisions, and  along with them the
 retention of urine.
   After that time repeated incisions  were made with similar 
DISEASES OF THE PERICRANIUM.
163
results.   The principal change in her situation then was, that
she got free of the fits of  insensibility upon the spot  being
pressed ; and the effect of the incisions continued longer, as
on several occasions she remained free from the retention of
urine for several weeks after the incisions were healed,  and at
one time enjoyed  good health for three  months.  She was
thus gradually restored to perfect  health.

  Since the publication of the former edition of this  volume,
I have seen several cases  of this very interesting affection,
presenting characters similar to those which I have mentioned
in the general description of it, and yielding to a free incision
of the part, after the symptoms had been of long continuance,
and  had resisted much active  treatment.   One  of them, in
which the symptoms were very severe, and of eighteen months
standing, has been described by Mr. Blacklock in the  Edin-
burgh Medical Journal for July, 1831.  In another of the pa-
tients, a clergyman, the affection seemed to have been produced
by a small  piece of plaster which fell on his  head from  the
ceiling of a church.  The injury at the time was of the most
trifling  description, but this  affection gradually supervened,
accompanied by a train of anomalous nervous symptoms,  which
greatly impaired his general health, and rendered him entirely
unable for his duty for many months.  He was quite cured by
the incision, which had to be repeated twice.
  In these cases, the seat of the  disease  was distinctly indi-
cated by the  tenderness on pressure of a defined  spot  of  the
pericranium.   But the following case  presents some  features
of great interest, from the  complete relief which was  afforded
by the same operation, though there had  been no  tenderness
at the part, and nothing that led  distinctly to  the belief that
disease of the membrane existed.  It has led me to  suppose
that there  are  cases of untractable affections of the head in
which this treatment might be beneficial, though not  distin-
guished by the symptoms indicating the disease which has led
to these observations.

   Case XCVI.—A man aged 39, upwards of eight years ago,
received an  injury on his  head from the wheel of a wagon.
It produced a sore which  healed in  about ten days.    Abou
eight months after this he  began  to be affected with attacks
of headach, which had continued to recur from that time,
though sometimes at long intervals.  When I saw him, along 
164         DISEASES OF  THE PERICRANIUM.

with Mr. Kennedy, in autumn 1833, he had been  suffering
from intense pain in the  head for two months.   During  the
whole of this  time he had been confined to bed, and unable
for any kind of exertion ; every kind of active treatment had
been employed without any relief;  and the case now exhibit-
ed every character of a fixed  and formidable disease of  the
brain.   As the principal seat of the pain, he referred to a spot
on the vertex, and from this the acute  pain seemed to dart in-
to the centre of the brain, and particularly towards the left ear.
The  spot to which he pointed on the  vertex,  corresponded
with that which  he  represented as the  seat of the original
wound; but no  cicatrix  could be  discovered, and there was
no tenderness  of the integuments, nor any other  appearance of
superficial disease.  All the usual remedies, however, having
been employed without benefit, I suggested a crucial incision
at this  part,  which was done with  complete  relief.   The
wound healed in nine days ; he soon after returned to his usual
employment as a baker, and, through the winter, enjoyed good
health.   During the present summer, (1834,)  he has  had a
return of headach, after exposure to great heat.   After it  had
resisted various remedies, a repetition of the incision was con-
templated, but, at present, the affection seems to be subsiding. 
PART  II.
OP THE APOPLECTIC AFFECTIONS.
  The remarkable condition which we call coma, or oppres-
sion of the brain, appears from the preceding observations to
be connected with various and very different conditions of that
organ.  We have seen it existing with extensive effusion, and
without any effusion; and we have  seen  extensive effusion
and extensive destruction of the cerebral  substance taking
place  without producing it.   We have seen the same want of
uniformity in regard  to the various other morbid conditions
which have been the subjects of the  preceding observations ;
and, upon the whole, if we are asked, what is that condition
of the brain which produces coma, I think our answer must be,
that we cannot tell.  We are not,  however, to sit down con-
tented with this profession of our ignorance, but ought, on the
contrary, to consider this conclusion as a  position of  much
importance, from which we are to commence a new course of
investigation.  In this course, putting away from us the theo-
ries which have been so often received as established princi-
ples,  we must restrict our inquiries to a patient investigation
of the phenomena of disease.
   In the investigation of the cases which  are more properly
referable to the head of apoplexy, we find the  same difficul-
ties which have met us in the inflammatory affections. A per-
son previously in perfect health falls  down suddenly, deprived
of sense and motion, and dies, after lying for some time in a
state of coma.   We find on examination a  large coagulum of
blood compressing the surface of the brain, or filling its ven-
tricles, and the phenomena of the disease appear to be distinct-
ly accounted for.  Another  person is cut off with the same
symptoms,  and we expect to find  the same appearances, but 
166
APOPLECTIC AFFECTIONS.
nothing is met with except serous  effusion, in no great quan-
tity, in the ventricles, or only on the surface of the brain.  A
third is  seized in the same manner, and dies, after lying for a
considerable time in a state of coma, from which nothing can
rouse him for an instant; and on the most careful examination,
we cannot detect in his brain the  smallest deviation from the
healthy structure.
   These facts have not  escaped the observation  of patholo-
gists at  various periods, and much difficulty was experienced
in accounting for them upon the old doctrine of compression
of the brain.  Hence arose  many speculations in regard to
those  cases in which no morbid appearance was met with on
dissection, or none that  was considered adequate  to account
for the disease.
   In a remarkable case of this kind, which occurred to Willis,*
he supposes that the  animal spirits were suddenly  extinguish-
ed or suffocated by certain malignant or  narcotic  particles.—
Seelmatter ascribes the affection to a sudden relaxation of the
nerves : Nicolai, to a spasm  of the  meninges ; and Lecat and
Weikard to a spasm of the nerves  and  vessels of the brain.—
Kortum endeavours to reconcile the discordant opinions of his
predecessors, by referring all these cases to a new species of
apoplectic affections, which  he styles Apoplexia Nevosa.  Up-
on the same principle, other modifications of apoplexy have
been  contended for, which have  been supposed  to  include
these obscure and inexplicable cases, as the Apoplexia Con-
vulsiva, and Apoplexia Hysterica  of Burserius,  Tissot, and
other writers.  Tissot mentions a woman,  who,  after com-
plaining for sometime of  headach, was attacked with a great
and sudden increase of pain, accompanied by loss of sleep,
and died in a short time.   On dissection no morbid  appear-
ance could be detected.   A young woman, mentioned by the
same writer, having, during the flow of the menses,  suffered
from a fright, the discharge stopped, and she became liable to
frequent leipothymia.  After suffering  from this  and various
other symptoms for several months,  she fell into . a profound
sleep, from which nothing  could  rouse  her; this continued
four days; she then came out of  it and appeared  to be reco-
vering, when, after several  days,  she was seized with severe
headach, anxiety, and convulsions, and died.  No morbid ap-
pearance could be detected in any of the viscera.  Lecat at-
* Willis De Anima Brutorum, part ii,.275. 
APOPLECTIC AFFECTIONS.
167
taches much importance  to a case which occurred to him, in
which, after fatal apoplexy, he found no morbid appearance
except a small quantity of extravasated blood, not exceeding
a tea-spoonful.   This, he contends, could not account for the
disease upon the principle  of pressure, but was to be consi-
dered as  an effect, rather than a cause,  of that spasm  of the
vessels, which he conceived to be the proximate cause of apo-
plexy.  This explanation did not satisfy his  contemporaries,
and various doctrines  were brought forward to account for
this  form of the disease.   Some maintained that the me-
dullary substance of the brain is much more susceptible of
compression than the cineritious; but the prevailing opinion
was, that there are certain parts of the brain, where, by re-
tarding the course of the animal spirits, slight causes of com-
pression  are capable of producing the most urgent  symptoms.
Hence arose  a new and  extensive controversy respecting the
origin and progress of these animal spirits, and the course by
which they make their exit from the brain.   This important
function  was by one assigned to the acqueduct of Silvius ; by
another,  to the fourth ventricle; by a third, to the infundibu-
lum; by a fourth,  to the choroid plexus and straight sinus ;
and fatal apoplexy was supposed to  be  produced by very
slight causes, existing at these particular parts, and even by
causes so minute as altogether to elude observation.   From
the number and variety of these speculations, we perceive the
difficulties which attend the pathology of apoplexy, and learn
the important fact, that  apoplexy has,  by extensive observa-
tion, been ascertained to be fatal without any morbid appear
ance, or with appearances so slight as to be altogether inade-
quate to account for the  disease.
   The most simple illustration of the  apoplectic state, is de-
rived from those cases in  which  it is  distinctly traced to an
external cause, and  ceases when that cause is removed.  A
boy, mentioned by Zitzilius, had drawn his neckcloth remark-
 ably tight, and was whipping his top, stooping and rising al-
ternately, when, after a short time, he fell down apoplectic.—
 The neckcloth being unloosed, and  blood  being drawn from
 the jugular vein, he speedily recovered.  Strangulation, when
 the neck is not dislocated, appears to be simply apoplexy.—
 A man brought after execution to Sauvages, was recovered by
 three bleedings, and  sat up and talked, his breathing and de-
 glutition being natural.  After a short time the part of his neck
 where the cord had been applied began  to  swell, so as evi- 
168   VARIOUS FORMS OF  THE APOPLECTIC ATTACK.

dently to impede the circulation in the veins of the neck: he
then became drowsy, his pulse and  respiration slow, without
dyspncea, and  in a few hours he died apoplectic.   A woman,
mentioned by Wepfer, recovered after execution under the same
treatment.  After her recovery she was for some time affected
with vertigo, which  subsided  gradually.   To  cases such as
these, we may add the numerous examples, in which persons
fall down suddenly in a  state of perfect  apoplexy,  and very
speedily recover under the appropriate  treatment, without re-
taining any trace of so  formidable a  malady.
   The apoplectic attack, as it occurs in such examples as
these, must be supposed to depend  upon a cause which acts
simply upon the circulating system  of the brain, producing
there a derangement which takes place speedily, and is often
almost as speedily removed.  What the precise nature of that
derangement may be, is a point of the utmost difficulty to de-
termine, and perhaps we have not data upon which  it can be
determined by legitimate induction.   The subject leads to
speculations of a very interesting kind, but it must be confess-
ed that they are in themselves in a  great measure hypotheti-
cal,  and that their application to the phenomena of  apoplexy
is also conjectural in a very great degree.   They may be wor-
thy of some attention, but must be kept entirely distinct from
our present course of inquiry, in prosecuting which, I  shall
now take  a general view of the principal varieties  of symp-
toms which occur in the  attack of apoplexy.

   The apoplectic attack is generally preceded by symptoms in-
dicating some  derangement of the circulation in the brain.—
The most remarkable of these are the following; headach, gid-
diness, sense of weight and fulness in the head, violent pulsa-
tion  of the arteries, and confused noises in the ears.  These
symptoms are  often accompanied  by  epistaxis, which may
give a partial  and  temporary relief; by loss of recollection,
and  incoherent talking, resembling slight intoxication ;  by af-
fections of the  sight, double vision, and temporary blindness ;
by drowsiness  and  lethargic  tendency.   We also frequently
observe indistinct articulation, and  other  partial paralytic af-
fections.   These are sometimes confined  to one limb, or part
of a  limb ; sometimes affect the eyelids,  producing inability
either to  shut the eye or to  open it;  and frequently impair the
muscles of the  face, producing a  slight distortion of the
mouth.   These symptoms,  and others of a similar Jand, mark 
       VARIOUS FORMS OF  THE  APOPLECTIC  ATTACK.    169

 the tendency to the apoplectic  state, and often appear for  a
 considerable time before the attack actually takes place.  The
 attack itself occurs chiefly under three distinct forms, which it
 is of importance to distinguish from each other.

   I. In the first form of the attack, the patient falls down sud-
 denly, deprived of sense and motion,  and lies like a person in
 a deep sleep ; his face  generally flushed, his  breathing  ster-
 torous, his pulse full, and not frequent, and sometimes below
 the natural standard.   In  some cases convulsion occurs, in
 others, rigid contraction of the muscles of the extremities ;  and
 sometimes contraction of the muscles of the one side, with re-
 laxation of  the other.   In this state of profound stupor, the
 patient may die after various intervals, from a few minutes to
 several days;  or he  may  recover  perfectly, without any bad
 consequence of the attack remaining;  or he may recover from
 the coma, with paralysis of one side.   This paralysis may dis-
 appear in a few days, or it  may subside gradually, or it  may
 be permanent.   Other functions, as the speeeh, may be affect-
 ed in the same manner, being speedily or gradually recovered,
 or permanently lost; and  recovery from the apoplectic  attack
 is sometimes accompanied by loss of sight.

  II. The second form of  the disease begins with a sudden
 attack of  pain in the  head;  the patient  becomes pale, sick,
 and  faint; generally vomits, and frequently, though not al-
 ways, falls down in a state resembling syncope ;  the face pale,
 the body cold, and the pulse very feeble.   This is sometimes
 accompanied by slight convulsion. In other cases, he does not
 fall down, the  sudden attack of pain being only accompanied
 by slight and transient loss of recollection.   In both cases he
 generally recovers in a few minutes from the first effects of the
 attack, is  quite  sensible and able to walk, but continues to
 complain of headach ; after a certain interval, which may vary
 from a few minutes to several hours,  he  becomes oppressed,
 forgetful,  and  incoherent, and  then sinks into coma,  from
 which he never recovers.  In some cases paralysis of one side
 occurs ; but in others, and  I think the greater proportion of
 this class, no paralysis is  observed.

  III.  In the third form,  the patient  is suddenly deprived of
the power of one side of the body, and of speech, without stu-
por ; or if the  first attack be accompanied by a  degree of stu-
                            22 
170
CASES  PRIMARILY APOPLECTIC.
por, this soon disappears; he seems sensible of his situation,
and endeavours to express his feelings by signs.   In the far-
ther progress of this form of the disease great variety occurs.
In some  cases, it passes gradually into  apoplexy, perhaps af-
ter a few hours ;  in others, under the proper treatment, the pa-
tient speedily and entirely recovers.   In many cases the reco-
very is gradual, and it is only at the end of  several weeks or
months that the  complaint is removed.  In another variety,
the patient recovers so far  as to be able to  speak  indistinct-
ly, and to walk, dragging his leg by a painful effort, and  after
this makes no farther improvement.   He may continue in this
state for years,  and be cut off by a fresh attack, or may die of
some other disease without any recurrence of the symptoms in
his head.   In n fifth variety, the patient neither recovers, nor
becomes apoplectic ; he is confined to bed, speechless and pa-
ralytic, but in possession of  his other faculties, and dies gra-
dually exhausted, without apoplexy, several weeks  or months
after the attack.
   These three  forms of disease  frequently pass into one ano-
ther ; but they are very often  met with, as  they are here de-
scribed, forming  affections which differ remarkably from each
other; and they  appear very naturally to arrange themselves
into the three classes which have been here referred  to ;—first,
those which are  immediately and  primarily apoplectic; se-
condly, those which begin with a sudden attack  of headach,
and pass  gradually into apoplexy ; thirdly,  those  which are
distinguished by  palsy, and loss of speech, without coma.
                       SECTION I.

          OF THE CASES PRIMARILY APOPLECTIC.

  The apoplectic attack is a sudden deprivation of sense and
motion, the  patient falling down  as in a profound sleep, the
face being generally flushed, and the breathing stertorous. In
tracing  the  farther  history of such an  attack, the following
circumstances deserve our particular attention.
  I.  In many  cases  the patient  speedily and perfectly re-
covers. 
SIMPLE APOPLEXY.
171
  II. In many cases the disease is speedily  fatal,  and we
find on inspection extensive extravasation of blood.
  III. In other cases which are fatal, generally after a longer
interval,  we find only a serous effusion, often in no great
quantity.
  IV.  In many fatal  cases, no morbid  appearance whatever
can be detected after the most careful examination.
  Thus the disease, in a pathological point of view, again
resolves itself into three very  important divisions ;—apoplexy
with extravasation of blood;—apoplexy with serous effusion ;—
and apoplexy without any morbid appearance, or what I propose
to call simple apoplexy.  The latter affection leads to specu-
lations of very great interest;  for, the phenomena of the dis-
ease appear fully to  establish the important fact, that there is
a modification of apoplexy depending upon a cause of tempo-
rary nature, without  any real  injury done  to the substance of
the brain;  that the condition  upon which this attack depends
may be removed almost as  speedily as it was induced ; and
that it may be fatal without leaving any morbid appearance in
the brain.

  As one of the terminations  of the apoplectic attack, I have
mentioned extensive extravasation of blood; but, in point of
fact, it will be found that this is not a common termination of
those examples which are immediately and primarily  apoplec-
tic.   The  cases which terminate in this  manner, in  general
belong to another class already referred to, and to be afterwards
particularly described, which  begin with a  sudden  attack of
violent headach, and pass into coma  more gradually.   The
remarks to be offered  under this section, therefore, will be
confined to the  two other forms of the disease, which  seem
to be nearly  allied to each   other,  namely, apoplexy  with-
out  any morbid appearance, and apoplexy with serous ef-
 fusion.
  R I.__Apoplexy without any morbid appearance, or
                    SIMPLE APOPLEXY.

   When  a person previously in perfect  health  falls down
suddenly deprived of sense  and motion, and dies after lying
for a certain time in a state  of apoplexy; and when, on the
inspection of such a case, we cannot discover in the brain any 
172
SIMPLE APOPLEXY.
satisfactory deviation  from the healthy structure, this is the
affection which I  propose to call simple apoplexy.   I abstain
at present from any speculations in regard to  the  nature of
this remarkable affection, and  shall confine myself to a state-
ment of facts calculated to establish its existence as  a disease
of the brain, which may in this state be fatal.

   Case XCVII.—A  woman aged about 30, of a full habit,
some years before her death had been affected with symptoms
in the head, accompanied by impaired speech, and partial loss
of recollection.   Some effects of this attack had continued for
a considerable time, especially in her speech, but by degrees
she had perfectly  recovered, and enjoyed excellent health for
a long period preceding the attack now to be described.  She
was stooping over a washing tub, when she was seized with
a violent fit of sneezing;  she almost immediately became in-
sensible, and would have  fallen  down had she  not been ob-
served and supported by some persons standing by her, who
carried  her  to bed  in a state of perfect apoplexy.   All the
usual  remedies were  employed  in  the most active manner
without the least effect in alleviating any of the  symptoms—
she lay with all the  symptoms of the most perfect apoplexy,
and died on the  following day.  On inspection, no vestige
of disease could be discovered in the brain,  or  in any other
organ.

   Case XCVIII.—A gentleman aged 24, had been observed
for some days to be dull and drowsy,  and  he frequently com-
plained of his head.  Not having appeared  at his usual time
one morning, his friends went into  his  room, and found him
lying  across  his bed, half dressed,  in a state of perfect apo-
plexy.   The attack was  evidently  recent;  and it was  sup-
posed that he had been  seized while he had stooped over his
basin in washing.   His face  was rather livid, his breathing
stertorous, his pulse slow, and  of  good strength.   All the
usual remedies were employed with assiduity, but through the
day there  was no  change in the symptoms.   In the  course of
the night he recovered considerably, so as to know those about
him;  but  in  a  short time after  he  relapsed  into coma, and
died early on the following day, little more than twenty-four
hours after the attack.
   Inspection.—There was a slight turgescence of the vessels
on the surface of the brain;  no other appearance of disease 
SIMPLE APOPLEXY.
173
could be detected after the most careful  examination.   All
the other viscera were in a healthy state.

  The following very important case I received from my friend,
the late Dr. Duncan ;  it occurred under his care in the Clini-
cal Ward, in May, 1829.

   Case XCIX.—A man aged 54, of a plethoric habit and
short necked, was admitted into the Clinical Ward  on 30th
May.  He was in a state of nearly perfect coma, speechless,
and with palsy of the right side, to such an extent that even
the intercostal muscle of  that side did not act.  The leg and
arm of the left  side were occasionally affected with  convul-
sive motions.   Breathing  stertorous—deglutition  much  im-
paired.  Pulse 74.  The affection was of three days' standing,
and had come on with vertigo—loss of vision—violent head-
ach and vomiting.
   All the usual remedies were employed in the most judicious
and active manner without benefit.    On the first of June,
there seemed to  be a slight return of intelligence, but he soon
relapsed into coma, and  died on the 3d, without any change
in the other symptoms.
   Inspection.—A most minute and  careful  examination was
made of the brain, without discovering any appearance of dis-
ease, except  that the  choroid  plexus seemed rather darker
than u$ual, and  the basiler artery was diseased at one spot.
By the  side  of  the artery, there was a spot of  the  cerebral
substance, no larger than  a barley-corn, which appeared some-
what softened, but  even this Dr.  Duncan considered as ex-
tremely doubtful.

   These, I think may be considered as fair examples of sim-
ple apoplexy in its idiopathic form;  I add the following ex-
amples of the affection supervening upon other diseases.

   Case C.—A  lady aged 50, had been liable for many years
to attacks of cough and dyspnoea, which were generally re-
lieved by opiates and  blistering.  On the  20th of December,
1816, she was seized  with  one of these attacks in the ordina-
ry form.  On  the 22d she was better, though her breathing
was still considerably oppressed.  On the  morning of the  23d
she complained  of headach, and wished not to be disturbed.
Soon after this she appeared to her family  to fall into a sound 
174
SIMPLE APOPLEXY.
sleep;  but some  time after, it was found to be perfect apo-
plexy, from which nothing could rouse her,-and she died about
five o'clock in the afternoon.  I saw her only an hour befoie
her death; she was then in  perfect coma, her lips  livid, her
breathing  quick and  oppressed, and  her pulse  frequent  and
feeble.
  Inspection.—On the surface of the  brain  the veins  were
turgid, and the substance when cut into, exhibited a remark-
able degree of vascularity; there was no other appearance of
disease.   The  lungs were distended, and much loaded with
thin mucus, but their  structure was tolerably healthy.  The
other viscera  were sound.

  Case CI.—A  lady aged  45, had for three months before
her death been affected with the following symptoms,—nau-
sea and a peculiar uneasy feeling about the stomach, particu-
larly after meals ;  a feeling of distention of the abdomen, cos-
tiveness of the bowels, and anasarca of the feet and  legs.
The appetite  was  tolerable, and  the pulse natural, but from
being remarkably strong  and active, she became feeble, sal-
low, inactive, and listless.  A variety of practice was employ-
ed for three months with little benefit;  the anasarca gradually
extended ; effusion took place in the abdomen, and there was
much reason  to suspect  that  it had also taken place in the
thorax; the pulse, however, continued of  natural frequency
and good strength.  On the evening of the 18th of May, 1816,
she was observed to talk hurriedly and incoherently.   On the
morning of the 19th, she  was in a state of stupor, from which
at first  she could be partially roused; but  soon after mid-day
it increased to perfect coma.   She then lay in a state of perfect
apoplexy, with stertorous breathing and much moaning, the
face rather pale, the pulse 72,  and of good strength, and she
died on the morning of the 20th.  The catamenia had  been
regular, except at the last period, which should have happen-
ed  about  the 12th of May.
  Inspection.—No disease could be detected in the head after
the most careful examination.   There  was considerable  effu-
sion both  in the thorax and the abdomen.  In the heart there
was considerable  hardness  about  the  root of  the  tricuspid
valves.  No  morbid  appearance  could be discovered in the
other viscera.

  I have  already referred to various cases  mentioned by the 
           APOPLEXY WITH SEROUS EFFUSION.          175

older writers, in which apoplexy was fatal, without leaving
any morbid appearance ;  and others are related by later authors
of undoubted  authority.   A man, mentioned by Dr. Stark,*
after complaining of headach  and giddiness, fell down in a
state of insensibility, with some convulsion.  He then lay in
a  state of profound apoplexy for  forty-five  hours, when he
died.   No morbid appearance could be discovered in the brain
on the most careful examination.  A  young lady, mentioned
by Dr.  Powel, after appearing for one day very heavy and
disposed to sleep, fell into a state of perfect coma, which was
interrupted only by  occasional  attacks of general convulsion.
Without any change in the symptoms, she died on  the third
day.  After the most minute examination, no morbid appear-
ance could be discovered  in the brain.  Andral has described
several cases of  complete and sudden attacks of apoplexy, in
which  nothing could be  discovered but slight appearances of
increased  vascularity on  parts  of the brain.  One of them,
which was fatal in  two days, was accompanied  by  hemiple-
gia.   Dr.  Bright has also described several cases, chiefly com-
plicated with diseases of the lungs, in which there were strong-
ly marked symptoms of  oppressed brain, while nothing was
to be discovered on dissection but some appearances of in-
creased vascularity.  Similar cases are related  by other wri-
ters, and, upon the whole, I think we have sufficient ground
for stating it as a fact, that there is a modification of apoplexy
which is  fatal, without leaving any morbid  appearance that
can be considered as accounting for the symptoms.
        § II.—Apoplexy with serous effusion.

  Case CII.—A gentleman aged 80, but vigorous and active,
and of rather a spare habit, about the 9th of June, 1813, be-
gan to be affected with loss of  recollection, indistinctness of
speech,  and flushing of the face.  He  appeared  to have at
times a  weakness of the right arm, being observed occasion-
ally to drop things from the right hand, but he did not admit
that he  felt any weakness of it.  He complained neither of
headach nor giddiness, but said he was weak, and did  not
feel himself right; the pulse was natural,  and of good strength.
After a  bleeding from the arm, followed  by purgatives and  a
* Works of Dr. VVm. Stark, page 73. 
176        APOPLEXY WITH SEROUS EFFUSION.
regulated diet, he seemed to be much improved;  he had in a
great measure  recovered his recollection, and  had lost  the
flushing of his face; and his speech was much more distinct.
He walked out regularly, and his step was firm and vigorous.
Soon after, however, he began to have a recurrence of confu-
sion of thought, particularly on the 27th, when, in endeavour-
ing to write a letter, he was obliged to relinquish the attempt.
He complained that he could  not make sense of it, nor spell
the words; the writing was scarcely legible, and the lines
were very crooked.   On the 28th he seemed much better.  On
the following night he slept ill; got up about four o'clock in
the morning,  and said he felt restless and uneasy; he walked
about his room for sometime, and then returned to bed. Hav-
ing soon after this become quiet, his family  did not disturb
him till between eight and nine o'clock, when he was found
in a state of perfect  apoplexy, his pulse 80 and  full, the  ap-
pearance of the countenance natural; he was  incapable of
swallowing, and in  a state of complete insensibility,  except
that he occasionally moved  his right hand.  He was largely
bled, after which he became exceedingly pale, and the pulse
continued for a  considerable time very weak, but without  the
smallest abatement of the coma.    The other usual remedies
were then employed without any benefit.   In this state of per-
fect apoplexy he lay for seven days, during which time there
was very little change in the symptoms.   He frequently moved
his right arm  and leg, but not the left; he occasionally scratch-
ed a herpetic  eruption which was  on the thigh, and  several
times moved his night-cap.   Once or  twice he was observed
to open his eyes slightly for a few seconds ; the pupil was na-
tural, and contracted when a candle was brought near it.  He
passed his urine in bed.  He never swallowed a drop  of  any
thing.   His pulse at first varied from 80 to 100, but afterwards
rose to 120.   In this state of perfect apoplexy he died on
the 5th  of February.  A few  days before his death, a  gland-
ular swelling appeared on his neck, from  which he evident-
ly felt pain, as  he drew away his head when  it was touched.
   Inspection.—A good deal of fluid  escaped  when the cra-
nium was opened; there was considerable effusion under the
arachnoid, and  in the ventricles; the quantity collected was
probably from three to four ounces.  No other morbid appear-
ance could be detected  in any part of the brain.

   Case CHI.—A gentleman aged 70, of a florid complexion, 
            APOPLEXY WITH SEROUS EFFUSION.         177

 but rather infirm in his limbs, had suffered repeated attacks of
 Joss of recollection, which were said by his family to resemble
 fainting fits.   At the  commencement of the illness of which
 he died, he fell down suddenly deprived of sense and motion.
 After some time he recovered from this state of perfect insen-
 sibility, but his speech was now inarticulate; he had lost the
 power of his limbs, and his right eye was distorted outward.
 He was then confined to  bed;  at times incoherent, at  other
 times  more distinct, but  always much  oppressed, bordering
 upon coma; his speech continued very inarticulate, and his
 pulse was generally about 100.   His strength sunk gradually,
 without any particular change in the symptoms ; and he died
 at the end of five  weeks.
   Inspection,—The ventricles of the brain were found distend-
 ed with colourless fluid, and there was a considerable quanti-
 ty under the arachnoid.   There was no other morbid appear-
 ance.

   Case CIV.—A man aged 41, of a very full habit, had been
 for some time affected with cough, dyspnoea, and anasarca of
 the legs, when  he became one day suddenly incoherent, and
 soon after fell into coma.  His breathing was much oppressed ;
 his face livid and  turgid ; the pulse somewhat frequent.   The
 coma was of that  kind out of which he  could be roused with
 difficulty so as to  answer questions slowly, and heavily, and
 often incoherently.  He died on  the 3d day.
   Inspection.—Much fluid was found in  the ventricles of  the
 brain.   The lungs were much loaded with  blood,  and  there
 was considerable effusion in the cavity.of the pleura.  In  the
heart the foramen ovale  was open, of the  size of a goose-
quill.

   In concluding this part of the subject, I shall only add the
 following remarkable case, for which I am indebted to Profes-
 sor Turner, of extensive effusion  in the cranium without any
 apopletic symptom.

   Case CV.—A gentleman  aged about 70, a man of talent
 and of genius, had been valetudinary and hypochondriacal for
 upwards of 30 years, having been  affected with a  variety of
 uneasy sensations in the  stomach, as indigestion, a sense  of
tightness across the lower part of the abdomen,  and  occasion-
ally attacks 6i dysuria.  In the beginning of 1817, he became 
178         APOPLEXY WITH SEROUS  EFFUSION.
feeble, listless, and unable for  any exertion either of body or
mind: during the day he was drowsy, but his  nights  were
restless and feverish.  His countenance was pale and sallow;
his pulse  from 76  to 84; his tongue slightly  loaded; his
bowels generally costive, but  easily moved  by medicine, the
operation of which was sometimes followed  by diarrhoea.  A
variety of remedies were employed without benefit.   He pass-
ed the summer  without improvement,  and  in  the winter his
complaints were aggravated.   They consisted as formerly of
heaviness, feebleness, and want of sleep, to which were now
added a troublesome  cough, and constant pain in the lower
part of the abdomen, with strangury.   His appetite  failed ;
his pulse increased in frequency ;  and he became daily more
and more feeble and emaciated.   In the beginning of March,
1818, he was confined to bed; his strength then sunk gradu-
ally, and he died on the  14th, having  retained  his memory
and all his faculties entire till  within a  few hours of his death.
He had never complained of headach or giddiness, and never
had any paralytic or convulsive affection.
   Inspection.—A copious effusion of transparent  fluid was
found over the whole surface of the brain under the arachnoid
membrane, which, in various places, particularly  at the poste-
rior part, elevated that membrane in the form of small blad-
ders, and separated some of the convolutions from each other,
so as to form depressions on  the surface of the brain.  The
ventricles were also distended with  fluid, but not much en-
larged.  The brain was in other respects sound  ; the viscera
of the abdomen were healthy.  The bladder was  contracted
and thickened, but there appeared to be no disease of the pros-
tate gland or the urethra.
   In the former part of this work, I have referred to  several
cases in which extensive effusion was  found in the  brain,
without any apoplectic symptoms.  The fluid in  one of them
amounted to  eight ounces, and several  other cases of the same
kind are on record.   Dr.  Marshall mentions a maniac, who
died of mortification of his feet; a few hours before death, he
became perfectly rational, yet  effusion was found both on the
surface of the brain and in the ventricles, amounting to more
than a pound.

   The apoplectic cases in which we  find only serous effusion,
constitute  that modification of the disease  which  has  been
called serous apoplexy.   In regard to this affection, or rather 
OF THE TERM SEROUS APOPLEXY.
179
 to this  mode of expression, I submit the following observa-
 tions.
   I.  The distinction which has been proposed betwixt san-
 guineous and serous apoplexy, is not supported by observation.
 The former is said to be distinguished by flushing of the coun-
 tenance and strong pulse, and by occurring  in persons in the
 vigor of life;  the latter by paleness of the countenance  and
 weakness of the pulse, and by affecting the aged and  infirm;
 and much  importance  has been attached to this  distinction,
 upon  the ground, that  the  practice, which  is proper and  ne-
 cessary in the one case, would be improper or injurious in the
 other.  I submit that this distinction is not founded upon ob-
 servation ;  for, in point of fact, it will be found, that many of
 the cases which terminate by serous effusion, exhibit, in their
 early  stages, all the symptoms which have been assigned to
 the sanguineous apoplexy ; while  many of the cases, which
 are accompanied by paleness of the countenance and  feeble-
 ness of the pulse, will be found to be purely sanguineous ;  and
 one modification of the disease  in particular will be described,
 in which these symptoms are very strikingly exhibited, while
 the disease is  found to be  sanguineous  apoplexy in its most
 hopeless form.   Portal has described  a series of cases which
 afford the same result; of three, which presented all the symp-
 toms  of serous  apoplexy, one was saved by repeated bleeding,
 and in the other two which were fatal, there was found  ex-
 tensive  extravasasion of  blood.   Case CI., lately described,
 forms a remarkable addition to these observations.   If  any
 case would be confidently considered as serous apoplexy, this
 was such.  Dropsical  effusion  had existed in the body for
 months; and in defiance of every remedy, it had  been pro-
 gressively gaining ground. There were symptoms indicating its
 existence both in the thorax and in the abdomen ;  the  patient
 then became comatose, with pale countenance, and died ;  but
 though  dropsy was  found in the othei* cavities, none could be
 detected in the brain.
   II. In other parts of the body, serous effusion is very sel-
 dom a primary disease ; it arises as a result either of  inflam-
 matory  action, or of impeded  circulation,  and takes  place
 slowly,  not accumulating at once in such quantity as to induce
 urgent symptoms.   It is, therefore, in the highest degree  im-
 probable, that it should occur in the brain as a primary disease,
land accumulate with such rapidity as to produce the  symp-
toms of an apoplectic attack. 
180
GENF.RAL  CONCLUSIONS-
  III. The quantity of fluid effused  bears no proportion to
the degree of the apoplectic symptoms.  We find it in small
quantity though the apoplectic symptoms had been strongly
marked and long continued ; we find it in large quantity when
the symptoms  have been slight;  and, finally, we find most
extensive  effusion in the brain where there have been no apo-
plectic symptoms at all.   The direct inference  from these
facts is, that in the cases of apoplexy with effusion, the pre-
sence of the fluid cannot be considered as the cause of the
apoplectic symptoms.
  The facts which have been related in this section  appear to
warrant the following conclusions.
  1. There is a modification of apoplexy, which is fatal with-
out leaving any morbid appearance that can be discovered in
the brain.
  2. There is  another modification, in which we find serous
effusion, often in small quantity.
  3. The cases which are referable to these two  classes, are
not distinguished from  each other by any such  diversity of
symptoms as can be supposed to indicate any essential differ-
ence in their nature.
  4. Without any apoplectic symptoms, we find  serous effu-
sion in the brain in an equal or in a greater quantity than in
the cases  of the second modification.
  5. It is therefore  probable, that in these cases  the effusion
was not the cause of the apoplectic symptoms.
  6. It is probable, that the cases of the first modification
depend upon  a cause which  is  entirely referable to  a de-
rangement of the circulation in the brain distinct from inflam-
mation.
  7. It is probable, that the cases of the second modification
are, at their commencement, of the  same nature with those of
the first;  and that the serous  effusion is to be considered as
the result  of that peculiar  derangement  of the  circulation,
which  constitutes the  state of simple apoplexy.   In other
words, it is probable, that the affection which has  been called
serous apoplexy is to be considered  as simple apoplexy termi*
nating by effusion. 
APOPLEXY WITH EXTRAVASATION.          181
                      SECTION II.

OF THE CASES OF THE SECOND  CLASS NOT PRIMARY APO-
                        PLECTIC.

  The cases to be described under this section differ remark-
ably from  those which are properly styled apoplexy.   They
are not at first apoplectic ;  or, if there be at the very first at-
tack loss of sense  and motion, this state is recovered from in
a few minutes, or perhaps seconds, without any remedy. The
prominent symptom, at the commencement  of the disease, is
a sudden attack of violent headach, the patient often starting
up and screaming from the violence of it.  Sometimes he falls
down pale, faint and exhausted, often with slight convulsion, but
recovers from this  state in a very  short time.   In other cases
he does not fall down, but feels a sudden and great uneasi-
ness in his  head, generally with paleness, sickness, and often
vomiting.   The first attack being so far recovered from that
the patient is often able to walk home, the symptoms  go on
under various  modifications.  The fixed pain in the head ge-
nerally continues, often referred to one side of  the head;  and
generally there is vomiting.  The patient continues for some
time, perhaps  an hour or two, cold and feeble, with  cadave-
rous  paleness of the countenance; his pulse weak and gene-
rally  frequent.   He is quite sensible, but oppressed.  By de-
grees he recovers heat and the natural appearance of the coun-
tenance, and the pulse improves in strength.   The face then
becomes flushed; he is more oppressed ; he answers questions
slowly and heavily; and at last sinks into coma, from which
he never recovers.  The  period  occupied by these changes
varies exceedingly in  different cases.   In one case to be de-
scribed, there intervened, from the  first attack  to the com-
mencement of coma, 5 hours; in a second, 12 hours; in a third,
3 days; and, in a fourth, not more than 15  or 20 minutes.
Death followed the appearance of coma in the first of these
cases in 7  hours, in the second in 32 hours, and in the third
in two days.  Other varieties occur which will be exemplified
by the cases.  Sometimes the coma follows so speedily,  that
the case closely borders upon the attack of simple apoplexy. 
182         APOPLEXY WITH EXTRAVASATION,
But I think there is almost always a certain interval of sense,
generally with violent complaint of pain, and not that imme-
diate  and complete loss of  sensibility which occurs in what
may be strictly called the apoplectic attack.  In Case CXL
again, after the first attack there was an interval of a fortnight,
without any urgent symptom; the complaint then returned,
and was speedily fatal.   In  Case CXII., which  seems to be-
long to this class, after the coma had continued for three days,
there was a complete recovery from it, succeeded by maniacal
delirium.  This, after seven days, was again followed by coma,
which in  three days more was fatal.   In Case  CIX. there
was  also, after  evacuations, a temporary recovery from the
coma, about  12  hours after its appearance, and  20 hours be-
fore death.
  As far  as my  observation ^extends, the cases which belong
to this class are generally fatal.  They form a modification of the
disease, remarkably different from the simple apoplectic state ?
and, on inspection, we find none of those varieties and  ambi-
guities which occur in the apoplectic cases, but uniform and
extensive  extravasation of blood.   From the whole history of
them, I think  there is every reason  to  believe, that they de-
pend  upon the immediate rupture  of  a considerable vessel,
without any previous derangement of the circulation, the rup-
ture probably arising from disease of the artery at  the part
which gives way.   At the moment when the rupture occurs,
there seems to be a temporary derangement of the functions
of the brain, but this is  soon recovered  from.   The  circu-
lation then goes on without interruption, until such a quan-
tity of blood has been extravasated as is sufficient to produce
coma.   In their whole progress, these  cases  are strictly ana-
logous to those of  extravasation on the surface  of the brain,
from external  injuries.  The patient recovers from the imme-
diate effects of the injury, walks home, and after some time,
perhaps an hour  or two, becomes oppressed and at last coma-
tose^   The extravasated blood being in this case removed by
the operation of the trephine, the coma disappears.   The va-
rieties of the symptoms  which occur in this form of the  dis-
ease, are such as we might  expect upon this view of the na-
ture  of the affection.   In some cases  it is probable that the
extravasation goes on progressively, until such a quantity has
been  accumulated as is  sufficient to  produce the  fatal coma.
In others there is reason to believe that soon after the rupture
has taken place, the haemorrhage is stopped by the formation. 
             APOPLEXY WITH EXTRAVASATION.          183

of a coagulum,  and after a considerable interval bursts  out
afresh and  is fatal.   This probably occurred in Cases CX.
and  CXI.; and  in such cases, the  two extravasations can
sometimes on inspection be distinguished from each other by
their appearance.  In other cases, again, the second extrava-
sation takes place in another part of  the brain;  and this pro-
bably occurred in Case CXII.   In this case the  temporary re-
covery  from the  coma was remarkable—the apoplectic state
having taken place two hours after the attack, and having
continued for three days.   At that  time, it is  probable, the
evacuations employed had  the effect of  restoring the circula-
tion, which then went on in a  very imperfect manner, until it
was again interrupted by the fresh extravasation.   The rapidi-
ty with which the disease advances, in cases of this class, will
of course depend in a great measure upon the size of the ves-
sel  from which  the haemorrhage has taken place.  In some
cases, it will be  seen  to be very slow in its progress, and, in
others,  extremely rapid,—a very short interval  taking place
betwixt the first  attack and the occurrence  of  perfect  coma.
Even in some of these cases, however, the patient survives  a
considerable time ; but in others the fatal event likewise takes
place with very great rapidity.  In  some  cases, again, the
slowness with which the symptoms advance is very  remarka-
ble.  A man, mentioned by Dr. Bright, first lost the power of
the thumb and two next fingers of the left hand, but continued
his work for four days, when he lost the  use of the whole arm.
A few days after this his leg became  weak,  and gradually
completely paralytic.   The case was fatal  in a month, with-
out perfect coma, and a coagulum was found in a cyst  in the
right hemisphere.
  The following selection of cases will  illustrate  the prin-
cipal varieties of this very interesting modification of  the
disease.
  § I.—The  coma  rapidly  supervening on the first
                        ATTACK.

   Case  CVI.—A clergyman aged 55, while delivering his
sermon during  the  morning  service  of Sunday, 13th  May,
1827, was observed to stop and put his hand to his head ; he
then attempted to go on, but talked indistinctly, and had evi-
dently lost his recollection ; he supported himself by grasping 
184         APOPLEXY WITH EXTRAVASATION.
the side of the pulpit.  Assistance being immediately given
him, he was taken out,  and at this time was speechless and
paralytic of the  right side, but appeared to be sensible.  He
became rapidly more and more oppressed, and, in about twenty
minutes from the commencement of the attack, had become en-
tirely comatose.   From the time when he was taken down from
the pulpit, he was pale and cold, and his pulse extremely fee-
ble ; and this state continued when I saw him, about an hour
after the attack ; so that, though a vein was opened, very lit-
tle blood could be obtained.  Gradually the circulation rallied,
and, in another  hour, a full bleeding  was obtained without
any relief.  All the other usual remedies were employed with-
out benefit.  From the time when the coma took place, there
never was the  slightest abatement of it; he lay with his eyes
shut, his countenance pale and sallow, but placid and without
distortion,—his pulse weak, the power  of swallowing lost, the
breathing  at first stertorous, afterwards slow and oppressed.
He lived in  this  state till  Monday at mid-day, about twenty-
four hours after the attack.
   Inspection.—There was extensive extravasation of blood in
the left ventricle, which  had passed  partly into the right by
laceration of the septum.   It seemed to have made  its way
into the ventricle from the substance of the brain on the outer
and anterior part, where there was a large,  irregular, lacerated
cavity, full of coagulated blood, and communicating with the
ventricle; all  the arteries of the  brain were  extensively os-
sified.

   Case CVII.—A  man aged 32, of a very full habit, while
sitting by the fire on the evening of the 3d September, 1804,
was suddenly seized with violent headach, followed  by vomit-
ing.  After a few minutes he began to talk incoherently,  and
soon after  fell down in  a state  of insensibility, accompanied
by a slight  convulsion.   His  face was extremely  pale, his
body cold, and his pulse scarcely to be  felt.  From this state,
which  resembled syncope, he  passed gradually into the  ap-
pearance of apoplexy;  and, three  hours after the attack, his
breathing was  stertorous, the body of natural  heat, the pulse
72 and of  good strength.  The face was  still pale, he had
frequent vomiting, and was incapable of swallowing, and there
had been no diminution  of the coma.   He now lay in a state
of profound coma, and died 29 hours after the attack, without
any change in the symptoms, except that, during the last 12 
APOPLEXY WITH EXTRAVASATION.
185
hours, the pulse varied from 100 to 112.   Large bloodletting
and the other usual remedies had been employed without the
least benefit.
   Inspection.—All the ventricles of the brain were found.dis-
tended with coagulated blood, which appeared to have burst
into them from an irregular, lacerated opening in the substance
of the brain.


§ II.--An  INTERVAL OF PERFECT RECOLLECTION FOR SEVE-
   RAL HOURS  BETWEEN  THE  ATTACK  AND  THE OCCRRENCE
   OF  COMA.

   Case CVIII.—A gentleman aged 46, of short  stature, full,
flabby habit, and sallow complexion,  a literary man, and very
sedentary, while speaking in a public  meeting  on  the  28th
April, 1807, was seized with an uneasy sensation in his head,
" as if his head would have burst,"  or  " as if the brain had
been too big for the skull."   This feeling soon went off, and
he continued his speech; but when he  had finished it he left
the room, and felt himself extremely unwell.  He had cold
shivering, nausea, and  repeated  vomiting;  complained  of
headach and faintness ; his face was pale, and his pulse fee-
ble.   After  some time he was  able  to walk home, where  I
saw him at nine, P. M., an hour or more after the attack.   He
then complained of violent pain in the right side  of his head,
which came on  in paroxysms, and, in  the intervals, he was
much easier; he had nausea and repeated vomiting; he felt
himself cold and faint;  his face  was pale and  sallow;  his
pulse  weak  and rather frequent; he  was  quite  sensible,  but
much  oppressed, and answered questions very slowly.   He
was immediately bled from the arm, and, the pulse improving
under the bleeding, it was continued to  about 30 ounces, but
without relief.   He became gradually more and more oppress-
ed, and. by  11, P. M., had sunk  into coma, with  stertorous
breathing, and complete  insensibility.   In this state he con-
tinued till six  o'clock on the following morning, when he
died.   More blood had been taken from the temporal artery,
and the other  usual  remedies employed without  the smallest
benefit.   During the  last  six hours of his life, the  pulse varied
exceedingly, being sometimes slow and  oppressed, sometimes
frequent and full, and the transitions from the one state to the
other  were  very sudden; a short time  before  death it  was
                            24 
186         APOPLEXY WITH EXTRAVASATION.
strong and frequent.   The pupil  of the  eye  had retained its
natural appearance, and no  paralytic symptom was observed
in any period of the attack.
  Inspection.—A large quantity of coagulated blood was found
spread over the surface of the brain, under the dura mater, in
all directions, chiefly on the right side.   The origin of it was
evidently from  the  substance of the right hemisphere, from
which it had burst outwards by a large ragged opening. This
opening communicated with a cavity in the  substance of the
hemisphere, which also was  full of coagulated blood.   Large
coagula were  likewise found  under the base of the brain,
around the cerebellum, and about the upper part of the spinal
cord.  In the ventricles  there was  about an ounce of serous
fluid.

  Case  CIX.—A  lady aged 70, healthy and active for her
years, had complained for a day or two of headach, but without
being confined, or her health otherwise affected, till the even-
ing of the 7th  August, 1816, when she suddenly screamed out
from violent headach, vomited, and then fell down in a state
resembling  syncope ; her face  was extremely pale, and her
pulse scarcely to be felt; and there was some  slight appear-
ance of convulsion.  She recovered in a few minutes and went
to bed.   Through the night she  was restless, vomited repeat-
edly, and three or four times fell into a kind of fainting fit, of
a few minutes duration.  In some of these she was reported
to have made a gurgling noise in  her throat, and to have shown
some convulsive motions of the arms; in the intervals she
was quite sensible, and complained of headach.   About eight
o'clock in the morning of the 8th she sunk into coma.  I saw
her  for the first time about ten;  she was then completely co-
matose ;  breathing stertorous ; face rather pale  ; pupil con-
tracted ;  pulse of  good strength and a little frequent.  The
usual remedies were employed, and in the evening she had so
far recovered, that, when raised  up in bed,  she took into her
hand a glass containing some purgative medicine, and drank
 it.   She seemed to attempt  to speak, but could not;  and soon
 after relapsed into  perfect coma ; pulse at night 112; there
 seemed to be  no paralysis.   (9th)  Continued in perfect coma,
 and died at four in the afternoon.
   Inspection.—In the anterior lobe of the right hemisphere of
 the brain, there was a cavity containing a mass of coagulated
 blood the  size of  a small  hen's egg.   From this cavity the 
             APOPLEXY WITH EXTRAVASATION.         187

blood had forced a passage through the substance of the brain
downwards, and had spread in all directions under the base
of the brain, and  upwards on  both  sides, betwixt  the dura
mater and the arachnoid, to such an extent, that portions of it
were found on the upper surface of the brain on both sides of
the falx.   The substance of the brain surrounding the cavity,
was soft and much broken down.  There was nothing in the
ventricles, and  all  the blood-vessels  appeared remarkably
empty.
§  III.—An interval of three days  between  the at-
          tack AND THE  OCCURRENCE OF COMA.

   Case  CX.—A gentleman  aged 18,  previously  in good
health, after using rather violent exercise  in the forenoon, had
returned home  before dinner, and was sitting near the fire,
when, without  any warning,  he started  up, pushed his chair
backwards with  violence, exclaimed, " Oh my head !" and
instantly fell on the floor insensible, and slightly convulsed.—
I saw him within 10 or  15 minutes after the attack.   By that
time he had recovered his  recollection, was sitting on a chair,
and was quite  distinct.  His face  was extremely pale, and his
whole body cold  and  shivering : he complained of severe
headach, and his pulse was weak and rather frequent.  Blood-
letting was immediately employed, and  his pulse improved
under it.   It was repeated after  a few hours,  with the addi-
tion of purgatives, and the other usual remedies.  The cold-
ness and paleness went off after some time, and he then com-
plained only of severe headach, with a feeling of stiffness of
his neck,  and  pain extending  downwards along the cervical
vertebrae ;  his pulse was rather frequent and of good  strength.
He continued in this state for  two  days, the headach varying
very much in  degree, and frequently complained,  chiefly of
his neck ; his pulse was frequent,  120 or more, and of good
strength ;  the other functions  were natural; he was quite dis-
tinct ; had the use of all his limbs, and could get out of bed
with little assistance, and sit up a  considerable  time.   On the
third day he began to be more oppressed, and  a little confus-
ed and forgetful;  the other  symptoms  as before.   On the
fourth he sunk very gradually into coma, and died on the 5th.
His pulse  had  continued from 120 to 140 ; there had been no
paralytic symptom; but, on the fifth day, there was repeated 
188         apoplexy with extravasation.

convulsion. Bloodletting and all the other usual remedies had
been emplyed without benefit.
  Inspection.—All the ventricles of the brain were complete-
ly filled with coagulated blood.  In the substance of the left
hemisphere there was a cavity formed by laceration of the ce-
rebral substance, filled  also by the  coagulum, and communi-
cating with the  ventricle.  There  was no other morbid ap-
pearance.


§ IV.—The  fatal  coma  occurring a fortnight after
                   THE  FIRST ATTACK.

   Case CXI.—A lady aged 56, enjoying  good  health, ex-
cept  occasional  disorders in the  stomach, on  Tuesday, the
30th July, 1816, walked out in perfect health ;  had  gone but
a very short distance, when she was seized with violent pain
in the head and  giddiness;  soon after, she lost her recollec-
tion and fell down.  She very soon  recovered her recollection,
and was carried home, being unable to stand.  She  was then
seen by Mr. White, who found her pale and faint;  the pulse
70 and weak.  She was  a little incoherent, complained of se-
vere headach, and had repeated vomiting.  The vomiting re-
curred frequently for two  days, and then subsided ; the severe
headach continued a week.  During this period, she was ge-
nerally confined to bed, but was sometimes  able to  sit up for
a short time ; her face was pale ;  her pulse from 70 to 76 and
rather weak;  she had some appetite,  but bad sleep.  She had
no paralytic symptom, and made no complaint except of the
constant pain of her head, which was always referred  to the
back part.  At the end of the week, this pain became much
less severe ;  she then  complained  chiefly of pain in the back
and limbs, and some dysuria ;  her pulse was as formerly, and
 her mind entire.   In this manner she passed another  week,
still confined to  bed, but,  towards the end of the week, she
 appeared to be much better.   On Tuesday, 13th August, ex-
actly a fortnight from the first attack, she was suddenly seized
with violent pain in  the head, chiefly referred to the back part
 of it; in less than an hour she became comatose ; and in three
hours more was dead.   The face had  continued pale, and the
pulse natural.  I did not see this patient during her life, but
 was present at the examination of the body.
   Inspection.—In the substance of the. anterior  lobe of the 
            apoplexy with extravasation.          189

right hemisphere of the brain,t there was a cavity filled by a
coagulum of blood, the size of a hen's egg.   From this cavi-
ty a lacerated opening led into the right ventricle, and  all the
ventricles were completely filled by coagulated blood.  A thin
stratum of blood was also found under the base of the  brain,
which seemed to have escaped from the ventricles, by forcing
a passage under the posterior pillars  of the fornix.  Around
the cavity in the right hemisphere, the substance of the brain
was much softened and broken down.   Both the kidneys were
unusually vascular; about  the right,  there was a remarkable
turgescence of veins, and an appearance of extravasated blood
in the cellular membrane behind it.
         § V.—Two  distinct extravasations.

  Case  CXII.—A lady aged 40, of a spare habit, on the
15th May,  1811, at two o'clock, p. m., was suddenly seized
with headach, accompanied by vomiting and diarrhoea:  and
at the same time began to talk incoherently.  She continued
to talk incoherently for two hours,  and then sunk into coma, v
I saw her at five ; she was then in a state of perfect coma;
face pale ; the skin rather cold ; the breathing soft and natu-
ral ; the  pulse 65, soft and rather  weak.  During the after-
noon, she had frequent vomiting and repeated diarrhoea ;  no
other change  took place in the symptoms.  Full bleeding was
employed and a blister on the head;  but  she was incapable
of swallowing.  (16th, 17th,  and  18th)  She continued in a
state of perfect coma; never opened her eyes nor showed the
least sensibility, except that she drew away her arm with vi-
olence when  she was  bled.    She  frequently moved all her
limbs, and occasionally turned in bed.  The pupil contracted
a little when a candle was brought near it;  the face was some-
times a  little flushed, but  generally pale.  The  pulse  was
from 70 to  80, and of good strength.   There had been no re-
turn of the vomiting or diarrhoea after the 15th.   Bleedings,
both general  and  topical, were  employed, with purgatives,
&c.   On the  evening  of the 18th,  she came out of the coma
rather  suddenly, like  a person awaking from sleep; looked
around her, put out her tongue when desired, and took what
was offered to her;  she also  talked a little, but  incoherently.
(19th and 20th) Much incoherent  talking; appeared at times
to understand what was said to her, but could give no account 
 190         APOPLEXY WITH EXTRAVASATION.

 of her feelings, only said, she was  " very bad;"  pulse  from
 70  to  80.   (21st, 22d)  Incessant  talking and delirium; at
 times unmanageable and attempting to  get  out  of bed ; at
 these times the face was flushed; at other times it was pale ;
 pulse varying  from 90 to 120, weak and irregular; appeared
 to be blind, but had the  use  of  all her limbs.  (23d) Highly
 delirious and maniacal. (24th, 25th) Became calm and ma-
 nageable, and at times very weak.  Pulse small and feeble,
 skin cold with a clammy sweat;  appeared at times to see and
 to know those about her.  (26th)  Relapsed into coma; lay
 with her eyelids half shut, and the  eyes  distorted outwards;
 pulse from  80 to 100, and rather weak;  face pale; was in-
 capable of swallowing.  Continued in a state of perfect coma,
 on the 27th and 28th, and died in the afternoon of the 29th;
 —the pulse had continued about 90.
   Inspection.—All the ventricles of the brain were full  of a
 dark-coloured fluid like coffee.   In the  substance of the right
 hemisphere, there was a cavity containing a coagulum of blood
 the  size of  a hen's egg.   This cavity communicated with the
 ventricle, and the substance of the brain immediately surround-
 ing  the cavity was very soft and  much broken down.   In the
 left  hemisphere, at its upper and posterior part, there was a
 cavity the size of a large walnut.  It contained a dark-colour-
 ed matter which appeared to be coagulated blood, but considera-
 bly changed in its appearance, being firmer in its texture than
 recent blood, and of a brownish colour mixed with portions of
 a  lighter colour, which appeared  to be diseased cerebral  sub-
 stance.   The substance of the brain surrounding  this  cavity
 was much softened and broken down.                  »

   Some part within the substance of the hemispheres, as in
 these examples, seems to be the  most common origin of the
 haemorrhage in cases of this class.  It is, however, sometimes
 found in the ventricles  only, though more rarely.   In the fol-
 lowing Case it was confined to the third and fourth ventricles.


 § VI.--THE EXTRAVASATION  CONFINED TO THE THIRD AND
   FOURTH  VENTRICLES, WITH  REMARKABLE  DISEASE   OF
   THE ARTERIES OF THE BRAIN.

   Case CXIII.—A gentleman aged 55, of a thin spare habit,
had,  about six months before his death, an attack of hemiple- 
APOPLEXY WITH EXTRAVASATION.
191
gia, which, after the usual treatment, subsided gradually. On
the 10th October,  1819, he complained suddenly after dinner
of giddiness and sickness ; he went into another room, where
he was found a few minutes after, supporting himself by a bed-
post ;  he was then confused and pale.  Being put to bed, he
soon became partially comatose, with muttering and frequent
attempts to speak.  I saw him more than an hour after the
attack.  He was  then  pale  and sallow, pulse soft, languid,
and rather slow.  His eyes were open, but he did not  seem
to comprehend  what was said to him.  A vein was  opened,
which  bled very  little, the  circulation appearing extremely
languid.   Some time after, he was bled again by Dr. Aitkin,
when the blood flowed more freely, but without  relief.   He
became completely comatose, and died about three o'clock in
the morning.
   Inspection.—In the lateral ventricles there  was  a considera-
ble quantity of bloody serum ; the third and  fourth ventricles
were full of coagulated blood.   The arteries  of the brain were
in a great  many places in a remarkably diseased  state, being
extensively ossified ;  and there was in many places a singu-
larly diseased  state of the inner coat of  the artery.   It was
much thickened, and of a soft pulpy consistence; and  large
portions of it could be squeezed out when a piece of the arte-
ry was compressed between the fingers.
   In the cases now described, the haemorrhage appears  to
have taken place  from the deep-seated arteries of the brain.
In the two following  cases,  for which I  am indebted to Dr.
Barlow of Bath, and Dr. Hunter of this  place, it appears  to
have been from the superficial vessels.
§ VII.—Extravasation on  the  surface  of the brain.

  Case CXIV.—A gentleman about 63 years of age, tall and
slender, and of temperate  habits, was seized with  apoplexy
on the morning of the 2d of May, 1822.   He was promptly re-
lieved  by bleeding, continued well  through the  day, and, on
the  morning of the 3d,  appealed free from complaint.   About
two o'clock, however, there was a return of the  attack, when
he was again bled copiously, but without the effect of restor-
ing consciousness.   He was now seen by Dr.  Barlow, and
all the usual remedies were employed in the most active man-
ner without relief.  On the 4th, he  was still comatose, and 
192
APOPLEXY WITH EXTRAVASATION.
 continued so till ten o'clock at night, when consciousness re-
 turned, but continued only for a very short time.   On the 5th,
 he had an interval of recollection which  lasted three  hours;
 and he was  again sensible for about a quarter of an hour in
 the evening.  He had a similar interval for about an hour and
 a half on the 6th, but on the 7th was comatose  nearly the
 whole day.   On the 8th, there was a slight  return of con-
 sciousness in the morning ;  and towards the evening, he was
 sensible for several hours.   During these changes, the bowels
 had been fully opened, the pulse had continued about 72  and
 soft, and no paralysis of any limb had been observed.   On the
 9th, he was still lethargic, with some stertor;  but, after topi-
 cal bleeding and the operation of a  purgative, he was much
 relieved ; passed a quiet night, and on the morning of the 10th,
 he was quite sensible.  It was now first observed that he had
 lost the sight of the  right eye, which was  distorted  outwards.
 On  the  11th, he lay with his eyes shut, but  took  food, and
 answered questions intelligibly when he was spoken to.   On
 the 12th he was lethargic, but capable of answering questions
 when he was roused;  and this state continued on the  13th.
 On the afternoon of  that day, there was an increase of stupor,
 with difficulty of swallowing.   He was again partially relieved
 by leeches, a purgative, and a blister to the neck, but the  re-
 lief was  only temporary.   He became gradually more coma-
 tose, and died early  on the 16th.
   Inspection.—A copious  extravasation of. blood was found
 extended over the surface of the brain; it was closely adhe-
 rent to the dura mater, and could be peeled off like a mem-
 brane.    The substance of the brain was healthy.  There was
 no effusion in the ventricles.
   In the communication with which  Dr. Barlow has favoured
 me in regard to this-singular case, he remarks, "the frequent
 returns of consciousness seemed to warrant a hope that no  ir-
 remediable  extravasation had  taken place ;  yet the event
proved that extensive sanguineous effusionhad existed through-
 out.   Was the  lethargy owing to the extravasation ?—and, if
 so, why, under a  permanently existing  cause, was the effect
 so variable ?"  These  interesting queries I do not at present
 attempt to answer.

   Case CXV.—A man aged  about  35, keeper of a tavern,
 and addicted to the  constant use of  ardent spirits, had been
 drinking to intoxication during the night betwixt the 12th and 
            APOPLEXY WITH  EXTRAVASATION.         193

13th July, 1816; and, about seven o'clock in the morning,
was found lying in a state of violent convulsion.  No account
could be obtained of his previous  state, except that, during
the evening he had drunk a very large quantity of whisky,
and that, when he was  last seen  about three o'clock in the
morning, he was walking about his house, but unable to speak.
He was seen by Dr. Hunter, at a quarter  before  eight.   He
was then lying on his left side, in  a state of perfect insensi-
bility, with laborious breathing; saliva was flowing from his
mouth; his eyes were much suffused, and greatly distorted,—
the cornea of both being completely concealed below the up-
per eyelid; pulse 120, full and soft.   While Dr. Hunter stood
by him, he was again seized with convulsion ; it began  in the
muscles of the jaw^ which were drawn from side to side with
great violence, producing a loud jarring sound from the grind-
ing of the teeth.  The spasms  then extended  to the body and
extremities, which were first thrown into a state of violent ex-
tension and then convulsed for one or two minutes ; they then
subsided, and  left him as before in a state of  perfect insensi-
bility.   Similar attacks took place four times while Dr.  Hun-
ter remained in the house, which jtoas^ about half an hour; and
he expired in another attack of the same kind about ten mi-
nutes after.   Bloodletting, and every  other remedy that the
time  admitted of, were  employed in the  most judicious
manner.
   Inspection.—On removing the skull cap  an  appearance was
observed on the surface of the dura mater, of coagulated blood
in small detached  portions.  These appeared to have been
discharged from small  glandular-looking  elevations on the
outer surface  of the dura  mater, which were very vascular,
and highly gorged with blood.  There were depressions on the
inner surface of the bone,which corresponded with these bodies.
On raising the dura mater, th£re came into view a coagulum
of blood, covering and completely concealing  the right  hemi-
sphere of the brain;  it was about two lines in thickness over
the middle lobe, and became  gradually thinner as it spread
over the anterior and posterior lobes, and dipped down  below
the base of the brain.   The coagulum being removed, was
found to amount to about 3, ounces.   On the surface of the
left hemisphere, the veins were turgid with blood ; on the sur-
face of the right, they were entirely  empty ; but the source of
the haemorrhage could not be discovered.   There was no fluid
in the  ventricles, and no other disease was discovered.   The
                           25 
 194         APOPLEXY WITH EXTRAVASATION.

 stomach being carefully examined, was found to contain no-
 thing but air and some healthy mucus.
   The following case, for which I am indebted to Dr. Macau-
 lay, is altogether a remarkable one.  It is the most rapidly
 fatal case of cerebral disease that has occurred to me.

   Case CXVI.—A woman aged 54, who had been for seve-
 ral years liable to  headach, attended a crowded meeting on
 the evening of 25th June, 1829, and seemed in perfect health.
 Towards the conclusion of the meeting she uttered a loud and
 convulsive  scream, and instantly fell down in a state of insen-
 sibility.  She was immediately carried out  and was seen by
 Dr. Macaulay, who happened to  be present:  he found her
 pale and totally  insensible, and the pulse  feeble :  and within
 five minutes from the first seizure  she was dead.
   Inspection.—The integuments of the head were much load-
 ed with blood.   On removing the dura mater, there was a thin
 but very extensive appearance of extravasated blood, or rather
 ecchymosis, which covered  nearly the whole surface of the
 brain.   In  the substance of the anterior lobe of the right he-
 misphere there was a coagulum of blood the size of a  large
 bean.   All the other viscera were  examined in the most accu-
 rate manner, but nothing was discovered, except a tubercle
 on the liver,  and a small spot of ossification on the abdominal
 aorta.

   When the disease takes place in the  cerebellum, or  below
it, the symptoms  appear to be more rapid in their progress than
 when  it is in the  substance of the brain :  the two  following
 cases  will illustrate  this modification of the disease; for the
 second of them I am indebted to the late Dr. Hennen.
     § VIII.—Extravasation in the cerebellum.

  Case CXVII.—A woman aged about 70, a midwife, of a1
full habit and short stature, while sitting by  the bed of a lady
whom she was attending, suddenly exclaimed, "I am gone!"
and almost immediately fell down in a state of coma, with
some  vomiting.   She  lay in a comatose state,  without any
change in the symptoms for 40 hours, and then died.
  Inspection.—A  coagulum of blood, the size of a pigeon's ■ 
            APOPLEXY WITH EXTRAVASATION.          195

egg, was found in the right lobe of the cerebellum.   There
was no other morbid appearance.

   Case CXVIII.—A private in the 10th Hussars, of a spare
habit, about a month  before his death was attacked with  a
pain in the back of his head, for which a blister was  applied,
and the pain soon went off.  On the 22d July, 1819,  he was
seized with giddiness  and fell  down;  on being raised he vo-
mited, and complained of violent headach and faintness, but
was quite sensible ;  he was very pale, and his  pulse was slow
and languid.  Being carried to the hospital, he continued in
the same state; asked for cold water, which he swallowed,
and seemed relieved of the faintness, but continued very pale.
In a few minutes his eyes became fixed; he drew deep inspi-
rations, and in two minutes more was  dead.   From the mo-
ment of seizure, he did not move either the upper or lower ex-
tremities.
   Inspection.—Nothing unusual was discovered in the brain.
On raising the  tentorium, the vessels of the cerebellum ap-
peared very turgid.  On removing the cerebellum, a  coagu-
lum of blood of about two ounces was found under it, and
surrounding the foramen magnum.
§ IX.—Extravasation in the substance of the tuber
                       ANNULARE.

  Case CXIX.—A gentleman aged 37, had been for several
months in bad health, being affected with occasional tightness
of the chest and difficulty of breathing.   He had also severe
dyspeptic  complaints,  with  occasional  vomiting, a  yellow
tinge of his skin, and  considerable  uneasiness in the region
of the  liver.   For these  complaints he had been advised by
his medical attendants in the north, to go to Cheltenham, and
arrived in Edinburgh with that intention on 22d March, 1828.
I saw him on the following day along with Mr. Wishart.  We
found his pulse frequent, his countenance sallow, and his ex-
pression febrile and anxious.  He complained chiefly of tight-
ness across his  chest, with some pain in the region of the
liver.  Respiration was very imperfect along the right side of
the thorax, and there was some oedema of the legs.   By topi-
cal bleeding, purging, &c, he was considerably relieved;  and
on the 24th he expressed himself as feeling much better, but 
196         APOPLEXY  WITH  EXTRAVASATION.

his pulse continued frequent.   On the morning of the 25th he
was  suddenly seized with giddiness, noise  and confusion in
his head, and numbness of the whole right side.  He was op-
pressed, but not comatose ; answered questions distinctly, but
in a loud voice, and with a peculiar manner.   He complained
chiefly of noise in his head, of a tight and cramped feeling of
his right arm and leg, with much prickling and loss of com-
mand of the parts, but when desired to grasp another person's
hand with  his^ the muscular power  did not seem to be dimi-
nished.  The  expression of his countenance was vacant and
fatuous : the eye was natural.   The face  was slightly distort-
ed, and the speech was in some degree  embarrassed.   The
pulse was 120.
   After large  bloodletting and the  other usual remedies, the
symptoms  gradually  assumed a more favourable aspect, and,
after four or five days, he was  considered as being out of any
immediate  danger, though  the effects of the  attack were by
no means removed.  His pulse was  now natural, his speech
was  distinct, and his mind entire;  his sight was good, and
the appearance of the eye natural, except a slight degree of
paralysis of the upper eyelid of the right side.  His breathing
was  easy, and he made no complaint, except of the tight and
cramped feeling with numbness of the right arm and leg. His
look, however, continued vacant and  peculiar.  His appetite
and  digestion  were  good, and his  bowels  easily regulated.
He was improving in strength, and was able to be out of bed
part  of the  day.  This favourable state continued till the 14th
of April, on which  day he was found with  a very frequent
pulse,  without any other change in the symptoms.  This fe-
brile state  continued on the  two following days with  rapid
failure of strength, and he died on the evening of the 16th.
He continued  sensible to the last, and during this febrile at-
tack, he seemed to have acquired an increased command over
the limbs of the affected side.
   About the commencement of his illness of 25th March, he
complained of considerable uneasiness in passing his urine;
for a day or two it was bloody, and there was  a good deal of
tenderness  in  the  region  of the bladder!  After  a few days
this subsided, and he began to pass considerable quantities of
puriform fluid of  remarkable fetor, which  subsided  to the
bottom of the chamberpot, after the urine had stood for a short
time.  This continued  during the remainder of his life, though
it had  greatly diminished in quantity for several days preced- 
APOPLEXY WITH EXTRAVASATION.         197
ing the last febrile attack.   The urine was in sufficient quan-
tity and passed without difficulty.
  Inspection.—The brain and cerebellum were found in every
respect in the  most healthy state, and no vestige  of disease
was discovered  until the cerebellum was separated from the
tuber  anulare.   In doing so a cavity was exposed about the
size of a large hazel nut, lined by a soft cyst, and full of dark,
grumous blood of a firm consistence.  This remarkable cavi-
ty was formed partly in the  substance of the tuber, and partly
betwixt  it and the base of the cerebellum.   It was decidedly
more to  the left side than the  right, and the  surrounding sub-
stance was softened, and tinged with dark red points, as if
from injection of dark blood.  There was effusion  in the tho-
rax  to the amount of at least lb.  ii.   The right lung was con-
tracted,  and extensively hepatised ; the left was much loaded
with sero-purulent fluid.   The liver was very considerably
enlarged and of a pale-ash colour and granular texture.  The
left  kidney was pale,  indurated, and tubercular.   The inner
surface of the bladder was deeply injected, and in several pla-
ces  showed distinct round  ulcers  about  a quarter  of an inch
in diameter.
§ X.—Extravasation in all the ventricles and along
       THE WHOLE  COURSE  OF THE SPINAL  CORD.

  The following case shows the most extensive extravasation
of blood that has ever occurred to me.  It is also remarkable
from the period of  life at which the affection took place, and
its similarity in the symptoms to  one of the common inflam-
matory affections terminating by  effusion.

  Case CXX.—A boy aged 9,  previously in perfect health,
awoke in  the night  of  the 18th May, 1829, complaining of
headach ;  had vomiting  and slight convulsion.  On the 19th,
he was seen by Mr. W. Brown, who found him still complain-
ing of headach with occasional vomiting, but without any ur-
gent  symptom.  Under the  usual  treatment the complaint
seemed gradually to subside, and on the 25th he  appeared to
be entirely recovered.  But on the afternoon of that day, he
had a return  of convulsion, and in the evening  complained
much of headach.  Pulse 64.  (26th and 27th)  Said he was
better, but seemed  drowsy.   Pulse slow.   Bowels obstinate. 
198         APOPLEXY with extravasation.

—28th, had two attacks of convulsion, the second of which
was  very severe and continued for several hours, affecting
chiefly the left side of the  body.   Pulse 130.   On the  29th
he was again better;  but from this time he became gradually
more and more drowsy, and at last comatose with squinting,
and  occasional convulsive motions of the limbs, and he died
on the 3d of June.  His death was preceded by severe  con-
vulsion of several hours duration.   I saw him along with Mr.
Brown from the 29th.
  Inspection.—The surface of the brain was  healthy.  The
lateral ventricles were distended with  dark  bloody fluid, and
each of them  contained a mass of coagulated blood; that in
the right was  the  size  of a large walnut, the other smaller.
The  3d and 4th ventricles were quite  filled with  coagulated
blood in a very firm state, and from the bottom of the fourth
ventricle, the coagulum was traced outwards and spread along
the base of the brain and cerebellum, and around the medulla
oblongata.   The spinal  canal being now laid open, the  dura
mater  of the  cord appeared  remarkably distended,  and  the
cord was found through  its whole extent  entirely enveloped
by a very firm and uniform stratum of coagulated blood.  The
brain and cord were in their substance healthy, and the source
of the haemorrhage could not be discovered.


§ XI.—Extravasation  in a  cyst,  formed  by  separa-
   tion OF  THE LAMINA  OF THE DURA  MATER,  FROM RUP-
   TURE OF THE  MIDDLE  MENINGEAL  ARTERY.

   The following remarkable case was lately communicated
by Dr. John Gairdner, to the Medico-Chirurgical Society of
Edinburgh, and will appear, in a more detailed form, in the
next volume of their transactions.

   Case CXXI.—A man aged 48, about the 12th  of Novem-
ber, 1814,  was assisting a neighbour to carry a heavy load to
the top of a high stair, when he felt a sudden attack of head-
ach.   He was, from that time, troubled with headach and oc-
casional giddiness, increased by stooping;—and, after  these
symptoms had continued  rather more than a fortnight, he be-
came sensible of some imperfection of vision.  When seen by
Dr. Gairdner on the 2d of December, he  complained of vio-
lent  headach.   Pulse 40, and feeble.—The  pupils were at 
apoplexy with extravasation.         199
 this time  sensible to  the  light, but after a few days became
 insensible.  He sunk very gradually into coma, without any
 other remarkable symptom, and died on the 13th.
   Inspection.—On the left side of the head, a cyst was found
 in the course  of the  middle meningeal artery, occupying the
 region of the lower part of the parietal and upper part of the
 temporal bone.  It was formed by a separation of the laminae
 of the dura mater, and contained about four ounces of coagu-
 lated blood.   The portion of the dura mater forming the cyst
 was considerably thickened  and very vascular.  There was a
 depression on  the surface of the brain, corresponding to the
 cyst,—and the ventricles contained a considerable quantity of
 serous fluid.   There was no  other morbid appearance.

  The source of theghaemorrhage in cases of extravasation in
 the head  appears t^te exceedingly various.

  I. The most common is probably the rupture of a vessel of
 moderate  size in the substance of the brain,  from which the
 blood bursts by laceration either into the ventricles, or to the
 surface, or in  both these directions at once, as in a case de-
 scribed by Morgagni.  It is in vain in general to attempt tra-
 cing it to  particular vessels ;  Dr. Cheyne was able to do so in
 some instances; but, in general,  numerous vessels must be
laid open  by the extensive laceration, and hence, probably, the
 appearance which  has been  observed, as if the extravasation
 had taken place from various points at once.  A case  is de-
 scribed by Serres in which the rupture took place in the sub-
 stance of the pons Varolii; and from this the blood had burst
forth into  the occipital fossa.*
  II. The superficial vessels.  This  probably took place in
the  remarkable cases communicated by Dr. Hunter and Dr.
Barlow.   This appears to be the meningeal apoplexy of Ser-
res.   The blood seems in general to be accumulated betwixt
the dura mater and the arachnoid ;  and two cases of this kirrd
have been described by Andral; but cases have been describ-
ed by Fernelius and Tulpius, in which the blood  appeared to
be confined beneath the pia mater, and to have  been  discharg-
ed from the retiform plexus of vessels at the base of the brain.
In Case CXXXI., again, the cyst, which seemed to have con-
* Annuaire Med. Chirurg. 
200
apoplexy with extravasation.
tained the extravasation, appeared to have been formed in the
cellular tissue of the arachnoid itself.
  III.  From  ulceration and rupture  of one of the principal
arterial trunks.   Dr. Mills has described a case in which the
haemorrhage was distinctly traced to ulceration and rupture  of
the basilar artery; and a similar affection of the internal caro-
tid  is described by Morgagni and by Serres.
  IV.  From the vessels of the choroid plexus, as in a case
described by De Haen.   This  may probably be the source  of
haemorrhage in those cases in which it is confined to the ven-
tricle,  without any laceration of the substance of the brain.
In  Case  CX1IL,  it was confined to the third and fourth ven-
tricles.  Dr. Bright, also, has described a case which was fa-
tal  in twenty minutes, in which the extravasation, amounting
to about three ounces, was confined to the ventricles, without
any rupture of the cerebral substance.   H^.supposes it to have
proceeded from the vessels of the velum interpositum.
   V. Rupture of one of the sinuses, as in  a case described
by  Dr. Douglas,* in which the left latteral sinus was ruptured.
   VI.  From the rupture of small aneurisms in various parts
of the  cerebral vessels.  In a case by  Serres, such an apeu-
rism occurred in the basilar artery, which, when it was dis-
tended, was as large as a small hen's  egg.   A pound of blood
had been discharged by the rupture of it.  This man had been
long subject to a feeling of weight in the head, and, according
to his  own statement, to an indescribable stupidity, which was
much  increased by bodily exertion, and by strong liquors.  In
the Archives  Generales de Medecine, a case is described, in
which apoplexy followed the bursting of a small aneurism  in
the circle of Willis; and Dr.  Bright describes a case, which
occurred in a lad of 19, from the rupture of a small  aneurism
of one of the  smaller branches  of the middle cerebral artery.
   VII. In the Medical  and Surgical  Register of the Hospital
of  New  York, a  very  uncommon case is  described  by Dr.
Watts, in which the haemorrhage took place betwixt the dura
mater  and the bone, from  erosion of  a vessel in connexion
with caries of the inner surface of the parietal bone of the left
side.  The man was suddenly seized with hemiplegia of the
right side, and died in  five days.  The carious spot on the
inner surface  of the bone was not so large as a sixpence.  In
Case CXXL, I have described a form of the disease, equally
* Edin. Med. Essays and Observ. vol. vi. 
             APOPLEXY  WITH EXTRAVASATION.         201

uncommon, in which the extravasation took place, from  rup-
ture of the middle meningeal artery, in a cyst formed by sepa-
ration Of the laminae of  the dura mater.
   In the mbst  common  form  of this affection, in which the
haemorrhage proceeds from a vessel in the substance of the
brain, I have supposed the rupture to take place from disease
of the artery itself, without any relation to that congestive  or
haemorrhagic condition which seems to constitute the state of
simple apoplexy.    Such disease, accordingly, will be  very
generally found to exist in cases of this class.   It consists  in
some instances of ossification  of the arteries in various places,
and in others, of that peculiar earthy brittleness, which Scarpa
has  described as leading to aneurism; and the canal of the
artery will be found in many places  to be considerably nar-
rowed or contracted at the hardened parts, and sometimes en
tirely obliterated.  In other cases  again,  numerous  branches
of the principal arteries of the brain will be found to present a
succession of small opaque osseous rings, separated from one
another by small portions of the artery  in  a healthy state.
This is a  very common  appearance in the brains of elderly
people, and the rings are generally from half a line  to a line
in breadth, and are separated from each other by healthy por-
tions of about the same extent.  In some cases again the in-
ner coat of the artery is much  thickened, of a soft pulpy con-
sistence, and very easily separated; so that, when a portion
of the artery is compressed between the fingers, a considerable
quantity of this  pulpy matter  is forced out.  This  was  very
remarkable in Case  CXIII.    In a case of apoplexy very ra-
pidly fatal, which  occurred to the  late Dr. Duncan,  and Mr.
Wishart, they took  particular notice of  the remarkably dis-
eased  state of the arteries of the  brain,  which they describe
as exhibiting every  where the " earthy brittleness of  Scar-
pa."
   There is much reason to  believe, that this diseased condi-
tion of the arteries of the brain  may give rise to a variety of
complaints in the head;  and  that, after going on for a  con-
siderable time in this manner, it  may at  length be fatal by
rupture.    This  appears to  be probable  from the history of
many cases.   I shall only give the following as an example.

   Case CXXII.—A gentleman aged about 50, was for seve-
ral years affected with complaints in his head, which assumed
a great variety of characters.  He had at first attacks of gidr
                            26 
202
apoplexy with extravasation.
diness and headach, with loss of recollection and  impaired
speech.   These occurred from time to time, and  went off
without leaving any bad consequences.  After a year or two,
the symptoms became more  permanent, and he had violent
paroxysms of pain, which at one time were much relieved by
arsenic.   He then had  attacks bordering upon  mania, with
loss of recollection for several  days.  Afterwards he had epi-
leptic  attacks,  alternating with these maniacal paroxysms.
He next was affected with attacks of stupor of various dura-
tion.   The disease went on in  this way for several years ; and
he died at last in May, 1820, after an apoplectic attack which
continued eight or nine  days.
   Inspection.—Connected with the fatal attack, there was a
coagulum of blood, the size of an egg, in  the substance of
the right hemisphere.    The only other morbid appearance was
a  remarkably diseased  state  of the whole  arterial  system of
the brain.   It was most extensively ossified, with a thickened
and very diseased state  of the inner  coat of the arteries, and
partial separation of it from the other coats in many places.
Scarcely any branch could be traced through the whole brain
entirely free from  disease.  The  vertebral arteries  were also
much affected, especially the left, which was much enlarged,
and its coats thickened, ossified in spots, and brittle.
   The state of the arteries in such a case as this, with the par-
tial separation of the inner coat, could  not fail to be produc-
tive of much disturbance of the circulation, and much derange-
ment of the functions of the brain.   Another case will be af-
terwards  mentioned,  in which a similar disease appeared  to
have led to frequent paralytic  attacks ; the patient died at last
of gangrene of the toes.  (Case CXXV.)   See also the dis-
ease in the basilar artery described in case XXXV., in which
 it was entirely obstructed and distended by a firm white mat-
 ter, without any appearance of blood.
   It appears  that a disease  somewhat similar occurs in the
 veins of the brain, as in  the following remarkable  case with
 which I have been favoured by Dr.  Cheyne, of Dublin.

   Case  CXXIII.—A lady  aged 42, was  of a melancholy
 temperament, and had been  subject to headachs from  early
 life.   About ten years before her death, she lost her  husband
 under circumstances  of peculiar distress, and from that time
 confined herself to the  house, and laboured under the greatest
 dejection of mind.   She was liable to frequent attacks of bi- 
APOPLEXY WITH EXTRAVASATION.
203
lious diarrhoea, and her old headachs became more constant and
more severe.   In one of these attacks she became apoplectic,
and died.
   Inspection.-^There was a turbid effusion betwixt the arach-
noid and pia  mater, and  the whole surface of the brain was
bloodshot.    The venous system of the brain was diseased af-
ter an  unusual  manner.   There was a deposition of a firm
yellowish-white substance between the lining and  outer coat
of the veins ;  it was universal all over the brain, giving to the
veins a mottled or rather ribbed appearance.  The appearance
of the whole  of the arterial system was precisely the same as
the venous, and both the arteries  and veins were thicker but
more fragile than usual.   The medullary portion of the brain
was more than usually vascular; on the inner side  of the pos-
terior horn  of the left lateral ventricle, there was an irregular
cavity about  an inch  in length and half an inch in breadth.
The portion of the brain which formed the walls of the cavity
was much  diseased,  soft  and yellow; its  structure was de-
stroyed, and  it was penetrated by a number of  enlarged  and
unsupported  vessels.   The left choroid plexus  contained  an
hydatid the size of a large pea.

   This important subject  has been  little investigated, but
there seems every reason to believe that disease of the venous
system of the brain  may have a most  extensive influence in
the affections of that organ.   Various examples of this class
will be found in the  preceding observations, particularly  the
complete obstruction of the lateral sinus which occurred in
Cases IV.  and V., and the remarkable disease of the veins on
the upper surface of the brain in Case XXX.   The subject is
worthy of careful investigation, and promises important results.
A lady, mentioned by M. Gendrin, having been exposed to
mental  agitation  on  the seventh day after accouchment, be-
came insensible, and continued so for three quarters of an hour.
On her recovery, she complained of acute pain  in the left side
of the head,  which continued with little change for ten days,
notwithstanding topical bleedings, and various other remedies.
There  was then a great and sudden increase of it, accompani-
ed by pain in the left ear, and this was soon followed by pal-
sy, first of the right arm, and soon after of the right leg. Three
days after this, there  was loss of  speech with partial stupor,
then convulsive attacks, and strabismus; and she died on the
17th day of  the disease.  On inspection, the middle  cerebral 
204
PARALYTIC CASES.
vein on the right hemisphere, where it approached the longi-
tudinal sinus, was f«ind very large and containing a puriform
substance which entirely filled it: and the corresponding vein
on the left side was  in the same  state.   There was also ex-
tensive disease of the longitudinal sinus, its cavity, for several
inches, being  entirely degenerated into an irregular  cellular
mass, infiltrated with purulent matter mixed with blood.   In
the posterior part of the left hemisphere, there was exten-
sive ramollissement, mixed  with purulent matter.   The ven-
tricles were empty.  This affection is  also described by Dr.
Bright.  In a child, aged 20  months,  who died after an  ill-
ness  of  three weeks, with headach, squinting,  and  frequent
convusion, he found all the larger veins running into the lon-
gitudinal sinus, quite round and hard,  being filled with a yel-
low-coloured coagulum, as if they had been injected with wax.
This appearance extended through one  or two subdivisions in
some parts, and the longitudinal  sinus itself was found full of
a coagulum, taking the exact form of the sinus, which seemed
to  be almost  entirely composed of fibrin, with  a little of the
 red blood  in parts  and cavities.   There was effusion in  the
 ventricles, and ramollissement in various parts of the brain.
                      SECTION IIT.

 OF THE CASES OF THE THIRD CLASS, OR THE  PARALYTIC
                         CASES.

  Under this class I  have included a  description of cases
which  resemble each  other in their symptoms only, but are
found to differ most remarkably in the morbid  conditions  of
the brain with which they are connected.  We are not possessed
of sufficient information to enable us accurately to discrimi-
nate them from each other; and all  that-we can attempt,  at
present, is to  give a statement of the facts relating to them,
under a simple arrangement.
  The leading phenomenon of this class  is the  paralytic at-
tack without coma, or  at least without that complete and per-
manent coma which occurs in the former classes.  Some  of
those cases, indeed, which begin as a paralytic attack, after a 
       VARIOUS  FORMS  OF THE PARALYTIC ATTACK.    205

certain time pass into apoplexy, the paralytic attack being only
the prelude  to, or the first stage of the apoplectic; these  of
course belong to another class, particularly the second.  The
cases which I mean to include under this third class are those
in which, either  there has been  no apoplexy, or the apoplectic
state has soon passed off, leaving  the paralysis  as the more
prominent and permanent character of the disease.
   The attack appears under various forms ; the most common
of which is hemiplegia with loss of speech ; but in some cases
the speech  is not affected; while in others, the loss of speech
is at first the only symptom.  L~i some cases, again, one limb
only is  affected,  which  is most commonly the arm, though
sometimes the leg.   Numerous other modifications  occur, as,
palsy of one eyelid;  or of the orbicularis of the eye;  distor-
tion of  the eyes; double vision; twisting  of the mouth, &c.
Loss of the  power of swallowing  also occurs  occasionally,
though more rarely in the  cases which do  not pass into apo-
plexy.   The patient  frequently appears  quite sensible of  his
situation, and makes anxious  attempts to express himself;
generally understanding  in a great measure what  is  said to
him, and answering by  signs.   Sometimes, however, when
he retains a partial power of speech, his answers are  incohe-
rent and unintelligible.
   In the farther  progress of cases of this class, we observe
remarkable varieties, which may be chiefly referred to  the fol-
lowing heads.
   I.  Such an attack may be merely the prelude to the apoplec-
tic, and may pass into it after  a short  interval.   These cases
belong chiefly to the second  class.
   II.  The attack may, under the proper  treatment, pass off
speedily and entirely, leaving, after a very short  time, no trace
of its existence.
   III.  The recovery may be very gradual, the use of the
affected limbs being restored after several weeks or months.
   IV.  The palsy may be permanent;  that is, the patient, af-
ter a certain time, may recover so far as  to be  able to walk
 about, dragging his  leg with  a painful effort,  and to speak
 very imperfectly ; and after this, makes no farther improve-
 ment to the end of his life, which may be protracted for many
 years.
   V. In a fifth variety the patient makes  no recovery ; he is
 confined to bed, speechless and paralytic, but possessed of his
 other faculties in a considerable  degree, and  dies gradually 
206        PARALYSIS WITH  SEROUS  EFFUSION
  exhausted, after several weeks or months; in some cases with-
  out coma, in others with coma for a few days before death.
    In endeavouring to investigate the morbid conditions of the
  brain which are connected with these varieties, we find consi-
  derable diversities, which, in a pathological  point  of view,
  may be referred to the following heads.
    I. Many of the cases appear to have a close analogy to sim-
  ple apoplexy ;  and when they are fatal, present either no  sa-
  tisfactory appearance, or only serous effusion, often  in small
  quantity.
    II. Extravasation of blood of small extent, contained in de-
  fined cysts in the substance of the brain  or under the mem-
  branes.
    III. Ramollissement of the cerebral substance.
    IV.  Inflammation and its consequences.


  § I.—Paralytic cases, with  serous effusion, or with
               SLIGHT  MORBID  APPEARANCES.

   When  a paralytic attack of the most formidable appear-
 ance passes off speedily and entirely, without leaving any trace
 of disease, we may suppose that no  very serious  injury has
 been done to the substance of the brain ; and that the disease
 bears a close  analogy to the affection which I  have  termed
 Simple Apoplexy ; or, in other words, that the cause had con-
 sisted of a state of the circulation of the brain,  which is capa-
 ble of being speedily and entirely removed. Many cases again
 are  fatal,  and  present,  on dissection, only serous effusion,
 often in small quantity.  A man, mentioned by Morgagni, had
 palsy of the right  arm, and died apoplectic in two days.  On
 dissection, no morbid appearance was discovered, except se-
 rous effusion, both in the ventricles and on the  surface  of the
 brain.   Another had loss of speech, and palsy of the left side,
 and died comatose at the end of a month.   Considerable ef-
 fusion was found on the surface  of the brain, but very little in
 the ventricles.   A third had loss of speech and palsy of the
 right side,  then became comatose, and died in five days. The
 ventricles contained about two ounces of fluid ; there was also
 a good deal on the surface of the brain, which appeared to be
 most abundant on the right side.
  I have formerly given my reasons for believing, that serous
effusion in apoplectic cases is not a primary disease but  a ter- 
PARALYSIS  WITH  SEROUS EFFUSION.       207
mination of simple apoplexy; and I have  described cases in
which it existed to a considerable extent without paralysis.—
In the cases, again, in which it has been accompanied by pa-
ralysis, the quantity of  fluid has  borne no proportion to the
symptoms, and has been equally distributed over the brain ;
except in the case now quoted from Morgagni, in which too,
it is worthy of remark, it appeared to be most abundant on the
same  side with the disease.  From these considerations,  I
think we may conclude, that, in the cases now referred to, the
effusion was not the cause of the paralysis,  but the effect or
the termination of a certain state of the circulation in a part
of the brain, with which  the  paralysis had  been connected
from the first invasion of  the disease.   The whole phenome-
na of palsy, do indeed bear evidence, that certain cases  of it
depend upon a cause, which is of a  temporary nature, and ca-
pable of being very speedily and entirely removed.   We see
hemiplegia take place in the highest degree, and yet  very ra-
pidly  disappear;  but the  most  singular circumstance,  con-
nected with certain cases  of palsy, is, that we occasionally
see it continue without any improvement for many weeks or
months; and  then, from some  change which entirely eludes
our observation, take a turn for the better, and very suddenly
disappear. -
   I do not know  to what class I ought to refer the following-
case, but I shall introduce it here as the most remarkable ex-
ample  that has occurred to me, of long-continued palsy, with-
out any satisfactory morbid appearance.

   Case CXXIV.—A  gentleman aged 35, while  standing in
the street,  conversing with a friend, suddenly lost his speech ;
he recovered it after a  few minutes, walked home, and  made
no particular complaint.   In the evening of the same day, he
suddenly fell  from his  chair, speechless, and paralytic on the
right side, but without coma ; being sensible of what was said
to him, and  answering by signs.   He was  then  confined to
bed for several weeks without any change in the symptoms.—
At the end of three months, he had recovered so far the mo-
tion of his leg, as to be able tq walk a little, dragging forward
the leg by a motion of the whole right side of his  body.  He
afterwards improved considerably in  bodily strength, so that
he could walk for several miles ; but  his thigh and leg con
tinued to be dragged forward by the same kind of effort, with-
out any farther improvement.   He never recovered  any de 
208        paralysis  with  serous effusion.
 gree of motion of the arm or hand ; he  could  not even move
 the fingers ; his speech was very inarticulate, and his counte-
 nance was expressive of great imbecility of mind.   In this
 state he continued  without relapse, and without any farther
 improvement, for fifteen years, when he died at the age of 50.
 For a  month before his death,  he had  been declining in
 strength.  I saw him about four  days before he died, and
 found him in a  state resembling typhus ; his pulse frequent
 and weak; his tongue  very foul, and dry in  the middle; he
 made  no complaint.  He was not  then in bed, but was  con-
 fined to it  next day, and died in  three days more, of rapid
 sinking without coma.
   Inspection.—The membranes adhered firmly to each other,
 and to the brain, at a spot the size  of a* shilling, on the upper
 part of the right hemisphere.  There was a large quantity of
 fluid under the arachnoid membrane, and a considerable quan-
 tity in the  ventricles.  Near the posterior part of the longitu-
 dinal sinus, a small part of the sinus appeared to be thicken-
 ed in its coats, and the  inner surface of this part was dark-
 coloured and slightly fungous.   The  cauda equina was of a
 remarkably dark colour, as if it had been soaked  in  venous
 blood, but  without any change  in its structure.  No other
 morbid appearance  could he detected, on the most careful ex-
 amination, in any part of the brain or  spinal cord.

   The remarkably diseased state of the arteries of the brain,
 which  has been already referred to, as a  very common appear-
 ance in elderly people, may probably be the cause  of tempo-
 rary interruptions of the circulation, and  slight paralytic at-
 tacks,  which after some time may pass off from changes which
 elude our observation. Perhaps something of this kind occur-
 red in  the following case,  for which I  am indebted to Dr.
 Simson.

   Case  CXXV.—A gentleman aged 58, in 1805, was attack-
ed with hemiplegia of the  right side, without coma.   After
the usual treatment, he improved gradually ;  and at the end
of five  months, he had quite  recovered, except  that his right
leg continued rather weaker than the other.   In 1812, he had
 another attack, preceded by violent headach.   From this like-
wise he  gradually recovered, though his recovery was much
less perfect than after the former attack.   He had  four other
attacks betwixt 1812 and 1817, which were carried off by the1 
              ABSORPTION  OF THE COAGULUM.          209

 usual remedies, bloodletting  and purging.   In 1817, he had
 another  and severe attack,  likewise in the right  side ; his
 speech was unintelligible,  and his mouth much drawn to the
 left side.  He was relieved by bloodletting, &c, but from the
 effects of this attack he did not recover.  He remained para-
 lytic in the right side, his mouth twisted, and his  speech very
 indistinct.   In November,  1818, he began to be affected with
 gangrene of the toes, which advanced slowly, and terminated fa-
 tally in April, 1819. From the time of his first attack, in 1805, to
 the second, in 1812, he always became confused and felt head-
 ach, when  he. attempted  to read or write, so that he was
 obliged immediately to desist;  but after the attack in 1812,
 he was able to  read and write without any confusion or unea-
 siness, and even without the  use of spectacles, which he had
 formerly employed.
  Inspection.—The dura mater seemed considerably thicken-
 ed ;  the pia mater also seemed thickened, and was  very vas-
 cular.   There was extensive disease in the arteries of the
 brain, their coats being thickened, and  in many places ossi-
 fied. This was very remarkable in the principal trunks  of the
 carotids  and vertebrals, and was likewise traced into the
 smaller branches.   The internal carotids seemed considerably
larger than usual, and their coats were much thickened ; and
the vertebrals and  their brandies were affected in  the same
manner in a still  greater degree, particularly about  the tuber
annulare, where the basilar artery  was quite  brittle,  and gave
off its branches in the same condition.
  M. Gendrin has described a case of several months stand-
ing, in which nothing could be discovered but a diseased state
of one of the posterior arteries of the brain, and a  very slight
softening of part of the cerebellum.  There seems every rea-
son to believe that such cases often  depend upon disease of
the arteries of a portion of the brain.
§ H.__Paralytic cases  accompanied  by extravasation
              OF BLOOD OF SMALL  EXTENT.

  The symptoms which appear in connexion with extravasa-
tion of blood in the brain,  seem to depend in a great measure
upon the quantity that has  been extravasated.   In the cases
which go on to apoplexy, the blood seems in general to burst
bY laceration of  the cerebral substance, either to the surface,
                         27 
210        paralysis with extravasation.
or into the ventricles'.  In  the paralytic cases, it seems to be
confined to a certain defined cavity in which the haemorrhage
at first took place.  This may be in any part of the substance
of the hemispheres ;  the corpus  striatum  is a  very  common
seat of it;  and it may be found in the substance of  the pons
Varolii, or of the medulla  oblongata.   It may likewise take
place on the surface of the brain, as in Case CXXXI., in which
the cyst which had contained it was distinctly seen in the cel-
lular structure of the arachnoid.   Extravasation of  a certain
extent, either in the substance or on the surface, seems, in ge-
neral, to produce palsy of the opposite side; and as the quantity
increases, the case seems to pass into apoplexy ; but it appears
that extravasation may take place and produce fatal apoplexy,
without having  induced  paralysis.  Several cases have been
already  described in which this took place, though in all of
them there was  a considerable interval betwixt the attack and
the occurrence of coma.
   When the extravasation  is of more limited extent, so as to
be confined to a cavity of moderate size  in the substance of
the brain, the patient is in  general affected with palsy and loss
of speech, without perfect coma ; or, if there  be coma for a
time immediately after the  attack,  it passes* off  after  a certain
interval, and the prominent character of the disease  comes to
be the state of paralysis.    In the farther progress of  the cases
of this  class, we find  remarkable  varieties.  Some of them
pass, after a certain time, into fatal coma, even when the ex-
travasation of blood is  of no great extent; while, on  the other
hand, we shall find that the patient may recover entirely from
the effects of extravasation of a certain extent, and may even re-
cover from the immediate effects of very extensive extravasation,
and survive in a paralytic state for many years.  The  causes of
this difference seems to depend, in a great measure,  upon the
state of the surrounding cerebral substance.  When extravasa-
tion of small amount is fatal, it seems in general to be connected
with ramollissement of the cerebral substance to some extent
around  the cavity which  contains the coagulum.   There is
also some reason to believe, that extravasation of very small
extent, in fatal cases, may sometimes be considered as the effect
of the state of simple apoplexy; and that, in those instances,
the fatal event is not to be ascribed to the extravasation, but
to the state of simple apoplexy, which we have seen may be
fatal without either extravasation  or effusion.   This may be
considered as in some measure conjectural, but the other is
more a matter of fact; namely the effect of ramollissement of 
absorption of  the coagulum.
211
the cerebral substance surrounding the coagulum in producing
a fatal disease, while we see in other cases, extravasation of
greater extent entirely recovered from.  The ramollissement in
these cases seems to arise from a  diseased state of the arte-
rial  system  of the part, the  same probably which generally
gives rise to the extravasation.

   When the cerebral substance surrounding the extravasation
continues in a healthy state, we  find  that coagula  of very
great1 size are  gradually and completely absorbed.   This re-
markable change seems to  commence  at a very early period,
but to advance very slowly.  When we have  an opportunity
of seeing the  coagulum, so early  as fourteen or fifteen days
from the  attack, we find it  already considerably changed in
its  character from the  appearance of  recent  blood.   The
thinner parts have considerably disappeared, and the coagu-
lum has  become firmer in its texture, and of a dark brown-
ish colour.   In its farther progress, it assumes  a firm and
fibrous texture ;  the dark red colour is gradually lost, and the
last portion that remains is a small mass of fibrin of a  slight
reddish colour, which, after a certain time, also entirely dis-
appears.   The time required for this  process must of course
depend in a great measure  upon the  size  of  the coagulum,
but seems likewise to be in part regulated by other circum-
stances.  In case  CXXVIL, a coagulum, which  must have
been of very considerable size, had  entirely  disappeared in
less than five  months.   In case CXXX., it  was seen  partly
absorbed at the end  of three months.   On the other  hand,
Moulin found a small coagulum not quite gone at the end  of
a year ;  and Riobe observed some of the blood still  remain-
ing in a cavity of small extent, after twenty months.  In two
cases, Serres found a hard coagulum  of blood remaining, in
the one at the  end of two years, and  in the other at the end
of three years.
  While  these changes are going on in the coagulum, the ca-
vity in which  it is contained  becomes  lined  with a distinct
firm membrane of a yellowish colour;  and when the coagu-
lum has entirely disappeared, we find the cyst remaining, and
forming a distinct and well defined cavity, which is generally
entirely empty.  Bands of the same  yellow matter which
forms it are  frequently seen crossing it in various directions,
and producing a connexion betwixt its  opposite sides at these
points.   The French writers believe that the  cyst  is at last 
$12         PARALYSIS WITH EXTRAVASATION.
entirely obliterated; but I have never seen any thing to satisfy
me that it is so.   I have examined  such cysts at various pe-
riods of their progress, but have seen nothing like an approach
to obliteration, except the bands which I have now mentioned,
connecting their opposite  sides, unless in case CXXXII., in
which a part of the cavity did appear  to be obliterated by the
adhesion of its sides.   The  cyst appears to  be  distinctly or-
ganized, and  numerous bloodvessels have  sometimes  been
observed ramifying upon it.   It does  not appear  precisely at
what period this remarkable membrane  is deposited.   Riobe
describes it in one case, as existing three weeks after the at-
tack ; and, in another, he thought he observed the formation
of it begun in a very soft state, as early as thirteen days. M.
Gendrin has given an  interesting  description of  it in a case
which was fatal in thirty-six days.   The cavity was the size
of a pullet's egg, and was situated between  the thalamus and
corpus striatum.  The coagulum being carefully removed, the
cavity was found to be lined by a delicate semipellucid mem-
brane, which presented, when held up to the light, numerous
vascular striae.   The coagulum did not appear to have under-
gone any change; and the opinion of M. Gendrin seems to
be, that the absorption of the coagulum does not  commence
till this membrane is fully formed.
   In the cases which I have had an  opportunity  of observ-
ing, after the disappearance  of  the coagulum, the cyst has in
general been entirely empty.   It appears, however, that it has
been frequently observed by the French writers full of serous
fluid.   Their idea is, that serous fluid is deposited from the
exhaling vessels of the membrane, and is  again  absorbed,
after dissolving a part of the coagulum ; that in  this manner
the coagulum gradually disappears; and that the  membrane
then continues to deposit  and  reabsorb  the  serum, until the
cavity is obliterated.   I have already  stated, that  in my ob-
servation, cavities even of large size are found entirely empty.
Andral, however, has described several  cases, in  which the
cysts were  found  containing serous fluid, many  years  after
the symptoms had disappeared.
   Moulin has  described a case of seventeen years  standing,
in which the patient had continued paralytic, with wasting of
the affected limbs, and had never recovered  his speech.   He
found a cyst containing four  ounces of fluid which was tinged
with blood.
   As the absorption of the coagulum goes on, the symptoms 
             ABSORPTION OF THE CAOGULUM.          213

in some cases subside gradually, and entirely disappear;  but
in others the improvement is but partial, and we find that the
coagulum had been entirely removed, while the patient con-
tinued to be  affected with  a great degree of palsy to the  end
of his life.  In other cases again, the symptoms appear to go
off speedily, though there  was every reason to  believe that a
coagulum was present, and could not yet be absorbed.  This
probably occurred in case CXXX.   It  appears  that extrava-
sated blood may be absorbed  in the  same  manner  from  the
ventricles, though in cases of this kind it more  rarely occurs
in that situation.  A man,  mentioned  by Riobe, had  an at-
tack of apoplexy, which left him affected with palsy of the
left side.   He improved very gradually, and was  entirely re-
covered at the end  of eighteen months, when he  died of  pe-
ripneumony.   In the right lateral ventricle, there was a small
quantity of coagulated blood, and the  membrane lining  the
ventricle  was  of a  yellowish  colour,  and  much  thickened.
In Case CXXXL, I have described an example  of absorption
from the surface of the brain, the cyst being formed in  the
cellular structure of the  arachnoid, but  having the same cha-
racters as the cysts which are found in  the  substance of the
brain.

  The following selection  of cases  arranged  under several
heads, will illustrate this modification of the disease.   I shall
describe the first case at some length,  as it shows  very  re-
markably the various stages of this interesting affection.


  A.   The cyst empty—the patient dying of another disease.

  Case CXXVI.—A clergyman aged 29, had complained for
several weeks of frequent headach, which affected him chiefly
in the morning.   On  Tuesday,  30th  November, 1819, he
walked out in his usual health about  11 o'clock in the fore-
noon, and about half an hour after went into a shop, when he
was found to be speechless, and  with his mouth twisted to
one side.  He was immediately taken home; he had then  the
use of all his limbs, and was able to  walk about  his  room ;.
he talked incoherently and inarticulately, his mouth was very
much twisted to the left side, but he  seemed  to know  his
friends.  Soon after, he  became more incoherent and partially
comatose, but resisted violently when he was bled.  Pulse of 
214         PARALYSIS WITH EXTRAVASATION.
 natural frequency.  I saw him soon after the bleeding; he
 was then rather pale, and the pulse natural; he  made  eager
 attempts to speak, and when disturbed, sometimes  became
 violent; but his speech 'was quite inarticulate, and he did not
 appear to comprehend what was said to him.   After farther
 bleeding, purging, &c, he became more intelligent,  and on
 the following day,  1st of December, he was  much more sen-
 sible ; he knew those about him, and occasionally answered
 questions distinctly, when the answer that was necessary was
 very short; when he attempted more than this, he wandered
 into incoherence, and often appeared very anxious to  describe
 something—but not a word could  be  understood.   He had
 the use of all his limbs, and) occasionally got out of bed with
 great agility to obtain something which he wanted,' when he
 could not  make the  attendant comprehend  what he meant.
 Farther bleeding and purging were employed, and there was
 a progressive improvement.   On the 3d, he was able to speak
 correctly, though slowly and heavily,  as  if endeavouring to
 recollect a word which he meant to  make use  of.   He now
 gave a distinct account of his seizure  on the 30th ;  he said
 " he felt a violent headach attack him suddenly while he was
 pulling on his boots immediately before going  out, and that
 it continued after he went out; he remembered going into the
 shop of a person  whom he  named, and  the person telling
 him that he was very ill and must be  taken home."  From
 this time he improved progressively, and by  the  18th was in
 his usual health, except some slight remains of thickness of
 speech, and a slight degree of confusion for a few  minutes
 after first awaking in  the morning.   These symptoms soon
 disappeared, and he enjoyed very  good health till about 15th
 November, 1820, when he was suddenly seized in the after-
 noon with loss of speech and palsy of the right arm.  I saw
 him in an hour after the attack ; little or no blood could be
 obtained from a vein, but the  temporal  artery being opened
 very low down, bled freely to 20  ounces, when  he  became
 faint.  He then took purgatives ; next day he was much bet-
 ter, and in a few days the symptoms were entirely removed.
    He now continued well for about a month.   On the 16th
 December, 1820, he  went into the country on  horseback;
o about three miles  from  town he  was observed  by  a person
 who passed him, running by the  side of his  horse  nearly
 speechless, and with the appearance of  a person intoxicated.
 In this state he went to the house of a person with whom he 
ABSORPTION OF THE COAGULUM.          215
was acquainted, but could not make himself understood, and
soon  after his  arrival became  completely comatose.   The
usual  remedies were employed without any  immediate effect.
During the remainder of the  16th, and through the whole of
the 17th, he continued in a state of perfect coma, notwith-
standing repeated bleeding to faintness, and the other usual
remedies.   On  the  18th, about  five o'clock in the morning,
he came out of  the coma, and from this time recovered  gra-
dually.  On the 21st, he was  able to be  out of bed and  to
walk steadily, and was soon after restored to his usual health,
except that his speech continued  considerably indistinct.  Af-
ter some time, he began to  complain of headach, notwith-
standing very abstemious diet; this was relieved by bleeding,
and for a considerable time it  was necessary to repeat  small
bleedings once in two or  three  weeks.   In this manner  he
enjoyed tolerable health, but never entirely recovered from the
effects of the last attack;  his speech continued thick and
somewhat indistinct;  his mind was evidently weakened ; his
countenance was vacant, and  his temper  was irritable.  But
he engaged in all the ordinary transactions of life, and in the
lighter duties of his profession, such  as baptism and marriage ;
he never preached, though he was very anxious to attempt  it;
he had the use of all his limbs, and was able to take a great
deal of exercise.  He continued liable to headach, for which
he was bled occasionally,  and once had an attack of haemop-
tysis,  which went off in a few days.  He  continued in this
state till the 20th May, 1822, when he  began to be affected
with cough, dyspnoea, and frequent pulse;  and  of  this affec-
tion in the chest he died, on the  7th of June, without any re-
currence of the symptoms in the head.
  Inspection—In  the substance of the left hemisphere of the
brain, about the centre, and  about  equally distant from the
ventricle and the surface, there was a cyst an inch and a half
long,  and  one inch deep.  It  was quite empty, but was lined
by a yellowish firm membrane  of considerable thickness. This
membrane could be easily separated from the surrounding ce-
rebral substance, to  which it adhered very slightly.   In the
substance of the right hemisphere, in a situation exactly corres-
ponding to  the former, there was another  cyst of a similar
character but smaller.   It was a narrow sinus, and of a diame-
ter which could have  admitted a quill: it was like the other
quite  empty, but lined by the  same kind of yellow membrane ;
there was a small quantity of clear fluid in the ventricle; there 
216         PARALYSIS WITH EXTRAVASATION.
 was no other morbid appearance.  In the lungs, there was
 slight hepatisation and  extensive  disease of the bronchial
 membrane.

   Case CXXVII.—A gentleman aged 56, in one of the last
 days of June, 1826, while walking through the museum of the
 University of Edinburgh, was suddenly  seized with  loss of
 speech.   He walked  with  difficulty and  some assistance  to
 the house of a friend in the neighbourhood, where it was first
 observed that he had lost the use of his  right side.   After a
 short time he became nearly comatose, and continued so for
 some days.   After repeated  bleeding, purging, &c, he be-
 came gradually more  sensible; but  it was now found that he
 had lost almost entirely the memory of words, though he ap-
 peared to comprehend what was said to  him.   He gradually
 recovered the use of his  leg,  so as to be  able to walk a little.
 But his arm made very little improvement, and both his speech
 and his memory of words continued very imperfect; his recollec-
 tion of persons and events seemed to be tolerably good.  He
 was improving very gradually in  all respects, till  about the
 end of October, when he began to be affected with a disease
 of the chest, of which he  died in the end  of November.  The
 paralytic symptoms continued in a very considerable degree to
 the last, especially in the right arm,  and in his speech, which
 continued very indistinct.  I  saw him a short time before his
 death, along with Dr. Alison, to whom I  am indebted for the
 history of the previous attack.
   Inspection.—In the  substance of the left hemisphere, on the
 outer side of the ventricle, we found a cyst about an inch and
 a half long and one inch deep ; it  was quite empty, and lined
 by a yellowish membrane similar  to that  which has been de-
 scribed in the  former case.

   Case  CXXVIII.—A  lady aged  about 50, was attacked
 with hemiplegia in April, 1817,  and, after stupor of several
 days continuance, came out of it gradually with palsy of the
right side, and very indistinct speech.   It was several months
after the attack when I first saw her.   She was then in pretty
good general  health, but  with very little improvement of the
limbs.   She could drag the leg forward a very little, the arm
she could not move at all, and the fingers of the affected hand
 were bent inwards, and  could not be  made straight  but by
 some force.   Her farther improvement  was  very slow.   In 
             ABSORPTION OF  THE COAGULUM.         127

the course of 1818, she acquired more use of her leg, being
able to support herself with a stick, and to walk a few steps:
her speech also became more distinct, but the arm  continued
completely paralytic.   She had made no farther improvement,
when, in August 1819, she began to complain of breathless-
ness, and died rather  suddenly in a fit of dyspnoea.
   Inspection.—The ventricles  of the brain contained several
ounces of fluid, and it appeared quite evident to all who were
present at the examination, that the left ventricle was much
larger than the right.   On the outer side of the left ventricle,
and separated from it by sound cerebral substance of about a
quarter  of an inch in thickness, there  was a cyst  similar to
those described  in the former  cases ; it extended  longitudi-
nally nearly three inches, and was as much or more in depth ;
it terminated below in an  angle, corresponding with  the nar-
row edge of the middle lobe of the brain, which lies in the an-
gle of the sphenoid bone, behind the  clinoid process; the ca-
vity  extended here to within a quarter of an inch of the base
of the brain.   This remarkable cavity was entirely empty; it
was lined by a fine yellow membrane, and bands of  the same
substance with the membrane intersected it in several places,
connecting the opposite surfaces, which in other places, though
in  contact, were quite unconnected.  This membrane existed
throughout the whole cavity, and was quite obvious even in
the sharp angular termination already mentioned.  The brain
was in other respects healthy.   There was considerable effu-
sion  in  the  pleura, and extensive accumulation of puriform
mucus in the bronchial canals.
   B.  The cyst empty—the patient dying of a fresh  attack.

   Case CXXIX.—A lady aged 40, on the 10th of April, 1821,
complained in the morning of violent headach, and had some
vomiting; soon after she was seized with perfect palsy of the
right  side, with very inarticulate  speech, and  a  considerable
degree of coma.   She was relieved by the  usual treatment;
the symptoms subsided  gradually, and  in eight or ten days
she was  quite well.  She occasionally felt a slight degree of
weakness of the side which had been affected, but she mere-
ly expressed it by saying that it was different from the other,
and  she  continued to enjoy good health until August, 1822,
when she had another attack in which the right side was again
                            28 
218         PARALYSIS WITH EXTRAVASATION.

affected.   She soon  recovered from the immediate effects of
this attack, but the leg and  arm continued long very weak,
and her speech was indistinct, with considerable confusion of
thought, and,  during the  following  winter, she was able for
very little exertion.  In the summer  of 1823, she improved
considerably, so that shecould walk a good deal, leaning upon
the arm of another person ; her speech was more distinct, and
her mind very considerably improved.   It was, however, ob-
vious that the effects of the attack were  not entirely removed,
as she still dragged her leg a little in walking, and had  less
command of the right hand than  of the  left.   She was going
on in this manner, and in other respects enjoying pretty good
health, when, in  December,  1824, she  was suddenly seized,
while  sitting  at  breakfast, with  palsy of the left side,  and
twisting of the  mouth;  and soon  after became comatose,
with total loss of the power of swallowing.  She died in four
days.
   Inspection.—In the right hemisphere  of  the brain, towards
the anterior part, there was a coagulum of blood the size  of a
pigeon's egg;  it  lay on the outside of the ventricle, and close-
ly bordering upon it, but without  any communication.   In the
corresponding situation  in the left  hemisphere, there was a
cyst, running  obliquely backwards on the outside of the  ven-
tricle,  and quite distinct from it.  It was about an inch and a
half long, and nearly an  inch in depth; it was quite empty,
and lined by a soft yellowish membrane.  This lady was like-
wise affected with extensive disease of the ovarium, on ac-
count  of which I had seen her at different times, both before
and in the intervals of the paralytic attacks  along with Dr.
Beilby.


C.  Two  cysts empty—the coagulum partly absorbed from a
          third—the patient dying of a  fresh  attack.

   Case CXXX.—A man aged 56,  in the  end of November,
 1822, had an attack of hemiplegia of the right side, with loss
of speech, from which he recovered after the usual treatment;
 and at the end of a  fortnight was in his usual health, except
that he felt a  degree of stiffness  of the  affected limbs.   He,
however, made no complaint, but  returned to his usual em-
ployment, as keeper of a tap-room, and to his usual mode of
living, which was eating  and drinking without restraint.   He 
              ABSORPTION OF THE COAGULUM.          219

 continued  to  go on in this manner till the end of February,
 1823, when  he was found one  afternoon, in his cellar, lying
 in a state of perfect apoplexy.   He died  in thirty-six hours.
   Inspection.—In the left ventricle of the brain there was
 bloody serum, with some coagulated blood, which appeared
 to have burst  from a cavity in the substance of the hemisphere
 on the outer side of the ventricle.  This  cavity contained a
 coagulum of  the size  of a pigeon's egg, and communicated
 with the ventricle by a small ragged opening.  The surround-
 ing cerebral substance was in some places considerably soft-
 ened.   Behind  this cavity, but separated from  it by sound
 cerebral substance,  there was  a  smaller  cavity, which was
 seated in the posterior part of the left thalamus.   It contained
 a small quantity of grumous blood, of a very dark colour, but
 not sufficient  to  fill it, a great  part of the cavity being in a
 collapsed state.   Exactly opposite to  this  cavity, in the
 posterior part of the right thalamus,  there was  another ca-
 vity  capable  of containing  a  small  bean.   It was  quite
 empty,  but  lined by a firm soft membrane, of a yellow co-
 lour.   In prosecuting  farther the  dissection of the brain, a
 fourth  cavity was met with  in  the substance of  the medulla
 oblongata, or  rather under the  pons Varolii; it  was capable
 of containing  a very small bean, but empty like the other, and
 lined by a similar membrane.   On inquiring farther into the
 history of this man, I afterwards  found that he  had had two
 attacks previously to the first of those above  described; the
 one eighteen  months  before his  death, and the other at a
 former period.  Both were said to have been very slight, and to
 have produced only numbness of his arm for a few hours; I
 could not obtain a more particular account.


                 D.  The cyst on the surface.

  Case CXXXL—A gentleman aged  74, in  April, 1823,
 had an apoplectic  attack which seized him suddenly in the
 evening.  He fell down deprived of sense  and motion, and on
 partially recovering, was found to be without palsy, except  in
his speech, which was quite unintelligible.   He had then con-
siderable stupor,*bordering upon coma, and at times showed
great restlessness and impatience in his ineffectual attempts  to
make  himself understood.  After large and repeated bleeding,
and the other  usual remedies, he gradually improved, so that 
220         PARALYSIS WITH EXTRAVASATION.
after six or seven weeks he was able to walk out, and was in
good  general health,  but with very inarticulate speech, and
considerable confusion of mind.  In conversation he was evi-
dently aware of what  he meant to say, but could not make it
intelligible to  others ; he put one word for  another, or  the
name of one  article for  another, often in a ludicrous manner;
he could not name persons, though  he evidently recognised
them; and, on  one  occasion, while  he was walking in  the
street with a friend, being very anxious to  say something to
him in regard to another gentleman whom he could not name,
he hurried his friend along to the door of the gentleman's house
and pointed to the name plate.   In this manner he passed the
summer, and the following winter, and great part of the fol-
lowing summer, being in good bodily health, but restless  and
unhappy in his mind, and with the same confusion of thought
and inarticulate speech.  He was incapable of reading a word,
or of expressing himself intelligibly on any subject,  except to
those who were  constantly with him, who got into the way of
understanding him on  ordinary topics.  In the end of sum-
mer,  1824, he began to  have complaints in his chest, of which
he died on the 19th of  December.  On the day on which he
died, he was more distinct in his mind than he had been at
any time  since the attack.
   Inspection.—There was an unusual quantity of fluid under
the arachnoid, so  that  at least eight ounces were collected;
and when it was all discharged the brain seemed remarkably
collapsed.  The arachnoid and the pia mater were considera-
bly thickened.  The  only other morbid appearance  was a de-
position of a firm yellowish matter, on the outer side  of the left
 hemisphere ; it  extended about three inches from before back-
wards, and in depth  corresponded to about  the lower half of
 the hemisphere.   This  substance when closely examined, was
 found to  be a collapsed cyst;  and it appeared to be formed
 betwixt the  arachnoid  and the dura mater,  or partly involved
 in the arachnoid.   It exactly resembled the substance which
 is found  lining  the cysts in the substance of the brain; and
 there seemed to be  little  doubt, that it had been the seat  of
 an extravasation which had been absorbed.  There was ex-
 tensive ossification of the arteries of the brain ; the substance
 of the brain was healthy.  There was considerable effusion in
 the thorax, with enlargement of the heart, and disease of the
 valves. 
ABSORPTION OF THE COAGULUM.          22l
  Attempts have been made in cases of this class to establish
a connexion between the seat of the disease and the particu-
lar organs which are affected ; but these attempts do not seem
to have been attended with much success.   Serres has con-
cluded that the arm is chiefly affected, when the extravasation
is in the posterior part of the hemisphere, and the leg when
it is in the anterior part, or in  the  corpus striatum.  Boml-
hrud has been at pains to  prove that  the speech is affected
when the disease is in the anterior part of the brain. But this
has been disputed in a memoir by Cruveilhier, where  he  de-
scribes several cases in which loss of speech was  a prominent
symptom,  while the disease was not in the anterior part of the
brain, but in some other part, as the middle lobes, and even
the cerebellum.  In one of his cases, a man was seized, in a
fit of passion, with palsy  of the left side and impaired speech.
He recovered after some months, but his speech continued a
little embarrassed.   After eight  years, he was attacked with
palsy of the right side, and difficulty of swallowing, and died
in ten days.   In the middle lobe of the left hemisphere, there
was a coagulum of blood the size  of  a  nut,  surrounded by
some ramollissement.   In the left lobe of the cerebellum there
was a cyst half an  inch  in diameter, lined  by an  organized
membrane, and containing a small  quantity of limpid  serum.
Another of his cases is sufficiently remarkable : A  man aged
48,  was first  attacked with loss of speech and twisting of the
mouth, which continued.   After six months, he was  seized
with palsy of the right side.  He recovered from this,  but his
speech continued much impaired.   After two years more, he
had a succession of attacks in which the right leg was first
affected, and afterwards the left leg; the embarrassment of
his speech was increased in each attack.   Finally,  at the end
of another year, he had  a fatal  attack, with  loss of speech,
loss  of the power of swallowing, and some vomiting.  In the
left hemisphere, there were three cysts near the surface.  In the
right hemisphere, there were two cysts in the corpus striatum,
and two in the thalamus. In the substance of the tuber annulare,
there was a, cavity containing recent blood not coagulated.—
In one of Dr. Cheyne's cases, there were three distinct extra-
vasations ; one in  the substance  of  each corpus striatum,  and
one in the third and fourth ventricles.  The  symptoms were
apoplectic with some convulsion, and  after  some time para-
plegia.   In  another, the  extravasation was  in the substance
of the pons Varolii, from which it had forced its way into the 
 222         PARALYSIS WITH EXTRAVASATION.

 fourth ventricle.  The symptoms were severe headach, follow-
 ed by perfect apoplexy without  paralysis.   In a  case which
 occurred to a friend of mine, there was a round coagulum, the
 size of a musket bullet, in the iter ad quartum ventriculum.—
 The attack consisted of paralysis of the left arm, in a few mi-
 nutes followed by apoplexy, which was fatal  in a few hours.
 In a singular case described by  Mr. Howship, the extravasa-
 tion wa*s distributed in the substance  of the  medulla oblon-
 gata, in such a manner as to form  several  thin  strata, alter-
 nating with  strata of the  cerebral  matter.  The  case was a
 sudden attack of perfect apoplexy, which was fatal in two
 days.  A remarkable case of the same kind is mentioned  by
 Dr. Duncan in his Clinical Reports.   Paraplegia is an uncom-
 mon occurrence in cases  of this class, insomuch  that it has
 been  doubted whether it ever arises from an  affection of the
 brain.* Serres has described a case of paraplegia, with palsy
 of the left arm, connected with  extravasation of blood under
 the right hemisphere of the cerebellum.  It occurred also in a
 case just quoted  from Dr. Cheyne, in connexion  with extra-
 vasation in the third and fourth  ventricles.   Another is men-
 tioned by Boerhaave,  in which it preceded  apoplexy,! and
 was connected  with extravasated blood under the  cerebellum,
 and about the top of the spine.   It does not appear, however,
 that in any of  these cases there was  an  examination of the
 spinal canal, so that perhaps we are not entitled to found any
 conclusion upon them;  the  subject deserves careful exami-
 nation.
   I conclude this part  of the subject with  the  following case,
 showing a  remarkable feature in this form of the  disease,
namely, loss  of the  cerebral substance to  a very considera-
ble extent,  at the place where the extravasation had been si-
 tuated.

   Case CXXXII.—A gentleman aged  64, was   first seized
with an attack of apoplexy in 1824, from which he recovered
under the usual treatment, but retained some imperfection  of
 speech, and a  degree  of weakness of the  left .side.  Some
months after, he had a second  attack, and in July,  1825,  a
third, accompanied  by convulsion, in which he lay in a state
 of insensibility for 36  hours, and was  not  able to leave his
 * See an able and ingenious paper by my friend Dr. Burder, in the Medical and
Physical Journal, for June, 1827. 
           PARALYSIS WITH RAMOLLISSEMENT.        223

room for a fortnight.  From this time to  the  period  of his
death in 1830, he  had a succession of apoplectic attacks,
amounting in all to  twelve.  After these attacks, he was ge-
nerally able to leave his room in  a few days, but each left him
more and more embarrassed in his  speech, and  paralytic on
the left side, with distortion of the mouth, and he died in the
12th attack in  1830, after an illness of eight  or ten days ;
during which, he lay in a state  of nearly perfect coma,  with
total loss of speech and perfect palsy of the left side.
   Inspection.—On removing the  dura mater, a remarkable de-
pression was found  on the surface  of the right hemisphere,
forming a deep and well-defined cavity, capable of containing
from three to  four ounces of fluid. It had been filled by a  clear
serous fluid, which escaped when the dura mater was wound-
ed in opening the head.  The surface of the cavity presented
nothing different from the ordinary appearance  of the cerebral
surface, being covered by the pia mater and arachnoid ; but
the dura mater had been separated by the fluid  which had fill-
ed the cavity.   On cutting into the cerebral substance which
formed the cavity, it was found more dense than  natural, and
a cavity was exposed in the  substance of the hemisphere im-
mediately beneath it, presenting  the usual appearance of the
collapsed cyst which had been the seat of extravasation.  It
was about an inch and a  half in length,—lined by a yellow
membrane of the usual appearance, and part of it was oblite-
rated by the adhesion of its opposite surfaces.   Several  other
very small cysts were observed in various  parts of the hemis-
phere,  but they were all empty, and  no appearance could be
discovered capable  of accounting for the fatal attack.


    § III.—Of the cases  accompanied by ramollis-
                         sement.

   In an early part of this work, I have submitted a conjecture
that the ramollissement of the cerebral substance is analogous
to gangrene in other parts  of the  body ; and  that, like  gan-
grene, it may arise from two very different causes.  These are
inflammatory action, and failure of circulation depending upon
disease of the arterial system. Ramollissement arising from the
former cause I conceive to be an affection which holds a pro-
minent place in the pathology of acute affections of the brain,
occurring in early life, and being accompanied by symptoms 
 224        PARALYSIS  WITH  RAMOLLISSEMENT.

 of an acute character.   I have given my reason for consider-
 ing this as an affection in many  respects distinct from the ra-
 mollissement, investigated with  such care by the French pa-
 thologists, and particularly M. Rostan.   This appears to be a
 disease of the aged,—the cases described by M. Rostan, hav-
 ing chiefly occurred in persons from 70  to 80, and upwards.
 It is accompanied by symptoms  of  a paralytic and comatose
 character, and is frequently complicated with extravasation of
 blood.  I have already alluded to the frequency and the extent
 of the disease of the  arterial system of the brain in advanced
 life ;  and  there appears to be  considerable probability  in the
 conjecture, that this may be the source of the ramollisement
 in the cases of this class.  The disease of the arteries consists
 of ossification, with thickening and contraction, frequently to
 a great extent, and  sometimes  with  separation  of the inner
 coat.   It  corresponds precisely with the state of the arteries,
 which we know to produce gangrene in other  parts  of the
 body, particularly  in the toes and feet of  old  people; and, in
 another place, I have described  a remarkable case, in which
 separation of the inner coat of the iliac artery produced gan-
 grene of the whole extremity,  which was fatal in four days.*
  The symptoms  accompanying the ramollissement, in this
 form, do not appear to differ remarkably from those which oc-
 cur in the other cases of palsy.  The attack is frequently pre-
 ceded by  some of  the usual symptoms indicating  a tendency
 to disease of the brain ; such  as, headach, giddiness,  partial
 loss of recollection, and numbness or prickling of some of the
 limbs.  After some time, there occurs suddenly or more gra-
 dually a loss of power of one or  more limbs, with  embarrass-
ment of speech, but without loss of intelligence.   The patient
is then confined to bed, helpless  and oppressed, with more  or
less of palsy, but with a certain  degree of intelligence ;  and
 dies  after  various intervals, either  with gradual sinking,  or
with coma for a few days before death, or  sometimes with
 symptoms of low fever.  The symptoms  seem frequently to
advance more slowly than in the  cases from  extravasation,—
one organ, as the tongue, being first affected, and then one or
more limbs after some interval.  Pain  in the affected limb is
also a frequent occurrence ; and rigid contraction of them has
been much insisted on, as a symptom characteristic of the ra-
mollissement.   It is, however, by no means  a uniform  symp-
* Edin. Med. Journal, vol. xvUj>. 308. 
PARALYSIS WITH RAMOLLISSEMENT.
225
torn, for it is frequently wanting  altogether ;  when it is pre-
sent in the early period of the disease, it  frequently disap-
pears in the course  of it; and in some of Rostan's cases, it
left the limbs  of the paralytic side  and affected those of the
other.  It is also frequently observed in cases entirely of  an-
other  kind—as in certain states  of fever which terminate fa-
vourably.   Convulsive affections of the limbs are also  occa-
sionally met with.
  The patient is frequently, in the early stages, quite intelli-
gent,  and observant of every thing, although unable to speak,
or able to speak but imperfectly.  As the disease  advances,
he frequently  becomes more oppressed and somnolent; but he
is intelligent when roused, not entirely comatose till the last
period, and sometimes  never entirely so.   In other cases,
there  is at first a considerable degree of coma, which after the
first day goes off, the patient becoming quite intelligent,  and
giving appearances of recovery, which are found to be falla-
cious. The sensibility of the affected limbs is in some cases
impaired, in others  little affected ; and, in  some  cases, they
are found acutely painful.   The  ramollissement is of various
extent.   It seems to be most commonly seated in the more
external parts of the brain, near the surface, but sometimes is
found in  more  deep-seated  parts, particularly in  the  corpus
striatum.   A small coagulum of blood is sometimes found in-
volved in the softened part; and sometimes  the softening is
found to  have taken place around the cyst of an old extrava-
sation.
   I have not seen much of  this form of the  ramollissement,
in its uncombined state; but it  seems to be  of very frequent
occurrence in the French hospitals.  The two -following cases
are the best examples of it I find among my notes.  The se-
cond  of them perhaps may be considered  as having some af-
finity to the cases of the inflammatory character; and, indeed,
some of M. Rostan's own cases afford traces  of inflammation.

   Case  CXXXIIL—A man aged  58, of a full habit and florid
complexion,  on the 7th of March, 1817, about nine o'clock in
the morning, without any previous  complaint, was found to*
have  lost  his speech.  I saw him  about half-past ten, and
found him  walking about his room; he had the full use of all
his limbs; understood  what was said to him, and  answered
by signs;  he could put out his tongue  freely, but  could not
articulate a word.   He  did not admit that he felt any uneasi-
                              29 
226        PARALYSIS  WITH  RAMOLLISSEMENT.
 ness in his head, his pulse was natural and of good  strength,
 and his face flushed.   The  usual  remedies were  employed
 through the day, without producing any change in the symp-
 toms.   In the morning of the 8th, he was found to be affect-
 ed with perfect hemiplegia of the right side ; and the tongue,
 when put out, was turned to the right side ; he was still quite
 intelligent, but made no attempt at speech.
   He now lay for a month without any change in the symp-
 toms ; he slept well in the night; in the day he was quite in-
 telligent, and answered by signs, but continued entirely speech-
 less.   For some time his tongue, when put out, was  turned
 to the right  side, but  afterwards ft  became strait.   He took
 his food, and appeared to suffer no pain; the pulse was natu-
 ral ; the right  side continued completely paralytic.   About
 the 10th of May, he began to have violent pain in the paraly-
 tic limbs, and could not bear to have them moved in the most
 gentle manner without  screaming; nothing was  to be seen
 about the limbs that accounted for the uneasiness.   For about
 a fortnight he now suffered constant pain; his strength sunk,
 and he  lost his  appetite.  He then  had some  vomiting, but
 not urgent;  his pulse became feeble, and his features collaps-
 ed ; and he  died in the end of May,  of gradual sinking, with-
 out coma.   There had been no recovery of speech, or of the
 motion of the right side.
  Inspection.—On opening the head, there appeared a remark-
 able depression on the upper part of the left hemisphere of the
 brain, about two inches in length and somewhat less in breadth,
 the dura mater sinking into it to the depth of about half an
 inch.   On removing the dura mater, the substance of the brain
at this place was to a great extent broken down, soft and pul-
py ; and this appearance  extended along nearly the whole up-
per part of the left hemisphere.   Tracing this mass backwards,
it was  found to be terminated by a coagulum of blood, not
larger than a small bean.   The coagulum was soft like recent
blood, and was situated  about two inches  from the  posterior
surface of the hemisphere, nearly on a level with the horizon-
tal part of the lateral ventricle.  There was no effusion in the
ventricle.

  Case CXXXIV.—A man aged 60, of rather a slender and
feeble habit, had complained for  nearly two months, of fre-
quent pain  in the right side of the  head, and an occasional
feeling of numbness in the left arm.   In the end of  Septem- 
             PARALYSIS  FROM  INFLAMMATION.         227

ber, 1818, this pain rather increased; he had twisting of his
mouth, dimness of vision of the left eye, and slight numbness
of the left hand.   After bleeding and the other usual remedies,
he was much relieved, and returned to his usual employment.
About a week after this, he was  suddenly seized with palsy
of the left side, and inarticulate speech ; his mind was distinct;
he seemed to have some headach, but not severe ;  his mouth
was drawn to the left side.   The usual remedies were employ-
ed without relief.  He continued in the most helpless state of
paralysis, being  unable to turn  from off his back, but quite
distinct, and able to express  all his feelings : pulse natural.
In this state he lived a month without any change of the symp-
toms, except that about a  week before his  death he was able
to move the  paralytic leg a little ; this slight  degree of motion
continued three  or four days, and  then ceased.   Two  days
before his death he was suddenly seized with perfect loss  of
speech; and this was followed in a few hours by coma, from
which he did not recover.
  Inspection.—The pia mater on the upper part of both he-
mispheres appeared thickened, and was remarkably vascular.
Both lateral  ventricles were distended with fluid.   The  sub-
stance of the brain was healthy, except on the  outer part  of
the right hemisphere, where  there was a considerable portion
in a state of complete ramollissement.   There was considera-
ble effusion under the arachnoid membrane.
 § IV.—Paralysis from inflammation, and its conse-
                        quences.

  This part of the subject it is only necessary to refer to very
briefly in  this place, in connexion with the general arrange-
ment of the sources of paralysis.  It has been already consi-
dered at some length in a former part of this essay, particularly
in connexion with  inflammation  of the  cerebral substance.
We have there seen paralysis, which had come on with  the
same rapidity as in the cases considered under the present sec-
tion, connected with simple inflammation  of the substance of
the  brain,—with  this inflammation passing into ramollisse-
ment,—and with  the encysted  abscess.   We  have likewise
seen it  coming on in a  more gradual manner, in connexion
with a very low inflammatory action in the cerebral substance,
which seems to terminate  by induration of the affected part. 
228        GENERAL  PATHOLOGY OF PARALYSIS.

I shall in this  place only add the following example of this
modification of the disease.

  Case CXXXV.—A gentleman aged about 60, whom I saw
along with Mr. William  Brown, had been for four years af-
fected with  paralysis  of the right side, and indistinctness of
speech.  Without any increase of these  symptoms he died
gradually exhausted by dyspnoea and general dropsy, connect-
ed with disease of the heart.
  Inspection.—In the anterior part of the left hemisphere, we
found a portion of the cerebral substance  the size of a  large
walnut, very much changed in  its  appearance, being of a
brownish-yellow colour; this portion was likewise much firmer
than the healthy cerebral substance, except at  its lower part,
where it was soft and approaching to suppuration.
  It is chiefly when  the patient  dies of  some other disease,
that we find this affection in the  state of  simple induration;
when it becomes itself the fatal disease, it is  generally by
passing on to partial suppuration or ramollissement.  Exam-
ples of this kind have been formerly referred to.

  In regard to the paralytic state in general, there are several
important circumstances which may be referred to very briefly.
In some cases of palsy there is loss of motion without loss of
feeling; in others, the feeling is lost also.  But some singular
cases are on record in which loss of  feeling took place  with-
out loss of motion.  Several examples  of this are described in
the Memoirs of the Royal Academy  of Sciences.  The most
remarkable is the case of  a soldier,  a  very strong  man, and
able for all his duties, who  had so completely lost the feeling
of his right arm and leg, that he  allowed the parts to be cut,
or red hot irons  applied to  them, without complaining of any
pain.   A gentleman, mentioned in the same paper, had a simi-
lar peculiarity in his right arm.*  Some interesting examples
of the  same  kind are described by Mr.  Broughton in the  Me-
dical and Physical Journal for 1827.    In a case which is re-
lated in the  Ephemer. Naturae Curios., there was loss of mo-
tion on the  one side, and loss of feeling without any diminu-
tion of motion on the other.f   A gentleman who was  under
the care of Dr. Hay of Edinburgh, had two paralytic attacks at
* Mem. de 1'Acad. Royale des Sciences, anno 1748.
t Eph. Naturae Curios. Cent. II. Obs. 196. 
GENERAL  PATHOLOGY OF  PARALYSIS.        229
the distance of eight months  from each  other.   In the  first
there was perfect loss of feeling, with only partial loss of mo-
tion ; in the second there was perfect loss of motion, with on-
ly, partial loss of feeling.   He  recovered perfectly from the
first attack after  a short  time;  but, after the second, though
he recovered partially, he continued to drag his leg, and after
a year or more died of  apoplexy.   It  is unnecessary to refer
the  scientific  reader to the light which  has been thrown on
this  curious subject by the discoveries of Sir Charles Bell.
   In cases in which there has been loss both of feeling  and
motion, we frequently observe recovery of feeling, without re-
covery of motion.   Berdotus, on the other hand, describes a
case in which there was recovery of motion without recovery
of feeling ;* a similar case is related by Burserius.f   Increas-
ed acuteness of feeling in paralytic limbs has also been observ-
ed ;  and I  have  referred to a  case, in which, connected with
disease in the brain, there was such  an increased sensibility
of the arm, that the least breath of cold air excited convulsion.
Dr. Falconer, in the  Mem. of the Med. Society of London,
vol.  ii.,  mentions a gentleman, who, after a paralytic  attack,
had  such a morbid  state of sensation, that cold bodies felt to
him  as if they were intensely hot.   When he first put on his
shoes, he felt them very hot,  and as they gradually acquired
the temperature of his feet, they appeared  to  him to cool.
Paralytic limbs  sometimes become  intensely painful without
any obvious cause;  examples of this have been given, and a
case has also been referred to, in which  recovery from palsy
was  accompanied by such pain, that the limb remained use-
less.   When  paralytic  limbs are recovering, the recovery
sometimes  begins at the extreme parts of the limb, as  the fin-
gers and  toes, and extends gradually upwards ; and sometimes
it begins in the part next  the body, and  extends gradually to
the extreme parts.   The  same variety occurs in the first at-
tack of paralysis, when it takes place so slowly as  to enable
us to observe its progress.   It seems in  general to begin in
the more extreme parts, but I have seen one patient who could
write distinctly with his arm supported upon a table after the
arm  from the shoulder to the elbow was completely paralytic ;
in a  few hours after the  hand was paralytic also.   M. Velpeau
has described the case  of a soldier in the  hospital of Tours,
* Act. Helvet. torn. vi. p. 191.
f Iustitut. Medicin. Pract. vol. iii. p. 76. 
230        GENERAL PATHOLOGY OF PARALYSIS.

who  had complete palsy of the right arm from the shoulder to
the middle of the fore-arm, while the hand was not in the least
affected.   He recovered in three months.*
   In regard to the temperature of paralytic limbs, I think it is
generally supposed, that they are colder than the healthy limbs;
but this does  not appear to be the case.   The truth seems to
be, that they have lost in some degree that remarkable power,
possessed by the living body in the healthy state, of preserving
a medium temperature; and that, according  to the tempera-
ture to which they have been exposed, paralytic  parts become
hotter or colder than sound  parts, which have been exposed
to the same temperature.^ A case has been related to me by
a friend, in which a medical man paying a visit  to a paralytic
patient, found the paralytic  arm so intensely hot that it was
painful  to  touch it.   This, upon  inquiry, was  found  to be
owing to the  application of very hot bran, which the patient
had made to the arm by the advice of a neighbour, though he
was himself insensible of the change of temperature.
   Some interesting phenomena are presented by the conditions
of the mental faculties, connected with the paralytic affections,
or which remain after recovery from the apoplectic.  One of the
most common is a loss of the memory of words, and this has
sometimes been observed to be confined to words of a particu-
lar class, as nouns, verbs, or adjectives.   The patient is  fre-
quently observed to have a distinct idea of things  and their
relations, as well as of persons, while he is entirely unable to
give them names, or to understand them when they are named
to him.  A singular modification of this  condition has been
related to me.  The gentleman to whom it referred could not
be made to understand the name of an  object when it was
spoken to him, but if the name was written he comprehended
it immediately.  Another frequent modification of the affection
consists in putting one word, or one name of an object in the
place of another; and a very singular circumstance  in some
cases of this kind is, that the patient always applies the names
in the  same  manner, so that  those who  are constantly with
him  come to  understand exactly what he means.   In one case
of this kind, a  gentleman, who was in other respects pretty
well recovered,  when he wanted coals  put upon his fire, al-
ways called for  paper, and when he wanted paper, he called
for coals, and these names he always used in the same sense.
* Archives Generales, January, 1825. 
GENERAL  P rHOLOGY OF PARALYSIS.       231
In other cases the patiei  seems to invent names, being words
which  to a stranger are quite unintelligible, but he  always
uses them in the same sense, and his regular attendants come
to know what he means by them.

   In the general pathology of paralysis there is much obscuri-
ty.   We find it connected with a great variety of morbid con-
ditions of the brain, and on the other hand we find all these
existing without producing it.   We cannot attempt to explain
these difficulties, and must content  ourselves  with  a  simple
view of the facts as they stand in the  present  state  of our
knowledge.   We have  found paralysis  connected  with the
following variety of morbid appearances.

   I. Simple and recent inflammation of  the cerebral sub-
stance.
   II. This inflammation passing into ramollissement.
   III.  The encysted abscess of the brain.
   IV.  Induration of a portion of the cerebral substance.
   V. Extravasated  blood in the ventricles; on the  surface
of the brain ;  and in cavities or cysts in the substance of the
brain.
   VI.  The empty cysts from which extravasation  has been
absorbed.
   VII.  Serous  effusion  on the surface of the brain.
   VIII.  Extensive  disease of the arteries of the brain.
   To this  enumeration we have also to  add the following
points which  have not arisen so directly out of the preceding
observations.
   IX.  Morbid changes  in small portions of the cerebral sub-
stance.   Several years  ago, I attended a gentleman who was
affected with  very slight palsy of the right side, which con-
tinued  for eight or ten months without becoming either better
or worse; he was  pale and  of a very spare  habit, and had
made very little complaint of his head.   He at last died co-
matose, after a few days  illness.  The  only morbid  appear-
ance was a portion  of the left hemisphere, at the very lower
part of the middle lobe, which was altered in its texture so as
to have  very  much the appearance of  fungus haematodes.
The part so diseased was about the size  of a large  walnut.
Several cases are described by Andral under the name of can-
cer of the brain, in  which  small portions were found in a state
of disease resembling  this.   The symptoms in general were 
232        GENERAL PATHOLOGY OF  PARALYSIS.
long-continued pain, referred to  one part of the  head, with
paralytic symptoms.
   X. Loss of a considerable portion of the cerebral substance.
One of the  most remarkable examples of this on record is a
man mentioned by Mr. O'Halloran,  who, after an  injury of
the head, lost a great part  of the frontal bone on the right
side.   The bone had been completely broken to pieces ; some
of the pieces were extracted immediately after the  injury, and
others  were discharged after a day or two.  A great opening
was thus formed,  and extensive suppuration having  taken
place, there were discharged  through it at each dressing im-
mense quantities of purulent matter, mixed with large pieces
of the cerebral substance, making, after some time, " a fright-
ful cavern"  in the  very substance of the  brain.   On the 8th
day of this  affection the left hand and arm became paralytic,
and the left thigh and leg on the 10th day.   The  man lived
to the 17th, retaining his faculties to the last, and having been
through the whole  course of the disease perfectly composed
and  intelligent, and his  pulse quite natural.   No account is
given of the dissection, or  of the actual  loss of the cerebral
matter; but  the report shows that it  must have been very
great.   "On the 8th day,"  Mr. O'Halloran  remarks,—" the
sore continued to   discharge  greatly, insomuch, that when I
affirm that not less  than three ounces of the brain,  with a hor-
rid smell, followed  every dressing,  I am  certain that I am a
good deal under the  quantity;"—and, again, on  the 13th
day,—"the cavern  was terrible, and I feared that the remains
of the lobes of the right side of the  brain would follow."—In
the conclusion of  this remarkable  case, it is added, that the
man "preserved his  intellect to the very moment  of dissolu-
tion."*
   XI.  Cold.  A man mentioned by Dr. Clerk, became para-
lytic in both legs, and partially in the arms, in consequence
of being much benumbed with cold  in travelling on the top
of a coach; he derived benefit from mercury and warm bath,
and was nearly recovered in  eight or ten months.f  I have
seen a case of paraplegia which was referred  to this  cause,
and which, when I  saw it last, had  continued  for  about four
years with very little improvement. .  Dr. Powel has described
three cases of paralysis of one side of the face, producing great
* O'Halloran on Injuries of the Head, p. 103.
 t Edinburgh Medical Journal; vol. iv. p. 266- 
GENERAL  PATHOLOGY OF PARALYSIS.        233
 twisting of the mouth, and in one of them, inability to shut
 the eyelids.   The affection  came on immediately after expo-
 sure to cold,  by a cold wind blowing upon one  side of the
 face;  it was not accompanied by any other symptom ; two of
 them were well in eight or ten days;  but a third, a child, was
 not free from  the complaint for three months.   They seemed
 to derive benefit from sudorifics and the application of steam.
 This was probably an affection of the portio dura.*
   XII. Local affections of nerves.  For the facts connected
 with this curious subject, I refer to the beautiful investigations
 of Sir Charles Bell.  One of the  most common examples is
 paralysis of one side of the face from an affection of the portio
 dura.   I have seen several examples of  it;  in some  of them
 it has been a transient affection,  and apparently connected
 with  some  inflammatory action about the external ear or the
 parotid gland ;  and it has  yielded readily to topical bleeding
 and blistering.  In other cases it is connected with disease of
 the bone, and proves most untractable.   The temporary para-
 lysis which arises from  accidental  pressure upon a nerve is fa-
 miliar to  every one;  but singular cases occasionally  occur in
 which the effects are more permanent.   An instance of this
 kind has been related to me in which the paralysis did not go
 off for several months, and another in which it was permanent.
 In the latter case, it took place in the fore-arms and hands of
 both sides, and was  induced  by pressure in consequence  of
 leaning for a long time  upon a bar  of wood while the person
 was  stooping forward in his anxiety to  witness some public
 exhibition.  Mr. Brodie has  described a case of paralysis of
 one side of the face which followed a blow on the cheek, and
 recovered in three months.
  XIII. There is a modification of paralysis which seems to
 be connected with the state of the circulation in the  affected
 part.   A lady, mentioned by Dr. Storer,t was recovering from
 a pneumonic attack, when one morning, after a restless night,
 she was suddenly seized with an acute pain in the left shoul-
 der, extending to  the  arm, and at the same time the whole
left side became paralytic.   The leg retained an obscure de-
 gree of motion and feeling, but the hand  and foot were insen-
sible to the prick of a needle.  The parts were cold, and all
the arteries in them were without pulsation.   On the right side

        * Transactions of the College of Physicians, London; vol. v.
 t Trans, of a Society for the Improvement of Medical and Surgical Knowledge,
vol', iii.
                         30 
234        GENERAL PATHOLOGY OF PARALYSIS.

of the body, the pulse was of good strength, and a little fre-
quent.  After a few hours the pain shifted to the leg and foot;
and she had also some  obscure  pain  in  the forehead, which
was  removed by bleeding with leeches.   The pain of the leg
and foot abated after twelve hours, and she had then no com-
plaint except  the paralysis.  For several days she seemed to
be improving a little in the motion of the parts, but they con-
tinued cold and without pulse;  on the fifth day, she had an
uneasy feeling in the epigastrium, with  sense of suffocation;
her breathing became  short and hurried, and she died in the
night; the body was not examined.  A gentleman, mentioned
in the same paper, was  seized with paralysis of the right arm
as he sat at breakfast, having been previously in perfect health.
He did not complain of any pain, but  the arm was pale, and
every part of it without pulse; in the left arm the pulse was
natural.  After four hours he became faint, with quick and
laborious breathing,  and frequent pulse; and, in two  hours
more, he died.  The body was not examined.   In the same
journal, Dr. Wells has  described  the case of  a  gentleman,
subject to cough and dyspnoea, who awoke one morning with
a severe pain in the left arm; In the afternoon it became be-
numbed and paralytic.   The pain then ceased, and the arm
was found  to be  without pulse.  He continued in this state
for two days, without any  other  complaint;  and on the third
day, he died suddenly, as he  got up to go to stool.  The pa-
ralytic arm only was examined after death, and in it no mor-
bid appearance could be detected.
  This singular affection was probably connected with  ex-
tensive disease of the arterial system.  Some years ago I saw
a woman, aged 73, who was suddenly seized with violent pain
of the whole  right  arm, accompanied  by palpitation  of the
heart, inclination to vomit, and pain extending across the tho-
rax from the breast to the back;  the pulse of the affected arm
was extremely weak; in the other arm it was 120 and strong,
but irregular.  After a  day or two the pain ceased, leaving
the arm without pulse, and  very weak, but not completely pa-
ralytic.  After ten days, the right thigh and leg were affected
in the same manner; after five days more, the left arm, and
ten days after this, the left thigh and leg went through  the
same  course.   She was  then confined to bed in a state of ex-
treme weakness, and no pulsation could be felt in any artery
except the  carotids, and a little in the  right humeral; in the
carotids it was strong and  frequent.  The radial artery felt 
           GENERAL  PATHOLOGY OF  PARALYSIS.        235

under the finger like a firm cord, as if permanently distended
with blood.  She still had pain in the region of the heart,
which at times was very severe, impeding respiration,  and
preventing her from lying on the left side.  She lived a month
in this state; the dyspnoea and palpitation became gradually
more  and more severe ; and  she  died, gradually exhausted,
two months after  the  commencement of the disease.   Some
days before death, slight pulsation was perceived in the arte-
ries of the left arm, and in the right it was more distinct than
formerly.   On  inspection much fluid was found in the peri-
cardium, and in the right cavity of the pleura.  The heart was
flaccid, and none  of its cavities contained any blood; in the
right sinus venosus, there were two firm fleshy tumors or poly-
pi ; the one the size of a pigeon's egg, attached to the side of
the sinus by a slender  pedicle, the other smaller and attached
more extensively.   The whole arterial system was extensive-
ly ossified ; in some places the diameter of  the artery was
considerably diminished by the ossification, and several of the
great  arteries were completely obstructed  by firm coagula of
blood in the contracted parts.   This was most remarkable in
the right common iliac, which was filled through  nearly the
whole extent of the common trunk, by a dark coloured coagu-
lum, which was firm,  elastic,  and  dry.  The left subclavian
was also  much  diseased and considerably contracted,  and the
aorta near the bifurcation was for about two inches almost en-
tirely ossified.
   There  are other  singular  facts which seem  to indicate pe-
culiarities in the  circulation in particular  parts  of the body,
probably  originating in the  obscure relation betwixt the  vas-
cular and nervous systems.  An esteemed  medical friend of
mine, now no more, when heated by exercise, perspired very
freely on one-half  of his body and not on the other, the line
being drawn with  great precision from the forehead along the
ridge of the nose, and so  downwards.  When he was very
much heated, the other side perspired also, but this only oc-
curred occasionally, from great exertions ; the singular  per-
spiration of the one side was a matter  of almost daily observa-
tion.   I knew another  gentleman who had the same peculiari-
ty, after being  affected with complaints in  the head, which
had threatened a paralytic  attack.   Sir Everard Home has
mentioned  a man who had palsy of the lower extremities from
a wound of the spinal  cord ; there was free perspiration of all
the parts above the seat of the injury, but none below it.  The 
236        GENERAL PATHOLOGY OF PARALYSIS.
same peculiarity occurred in a remarkable manner in a case of
disease of the spinal cord to be afterwards described.   A child,
mentioned by Dr. Falconer, became pale and emaciated on the
whole left side of the body, without any diminution of muscu-
lar  power, the right side  remaining healthy; she recovered
by the use of warm pumping.*
  The various forms of comatose affections which have been
described by systematic writers, seem to be  merely varieties
in degree, or modifications  of  the disease, of little practical
importance ;  but some of these  conditions are deserving of at-
tention.  The state  of lethargy, for example, presents some
interesting phenomena, in regard to the extent in which it may
exist without passing into apoplexy, and without  permanent-
ly injuring the functions of  the brain, though they are for a
time completely overpowered and suspended.   A man, men-
tioned by Mr. John Bell, who had been accustomed to a life
of much activity, was confined  from his usual employment by
an  extensive fistula which he had concealed.   Being of a full
habit, and his appetite unimpaired, he soon  sunk into a state
of  complete  lethargy, nearly his whole time being spent in
sleep.   When roused, he  attempted to answer questions, but
his answers were incoherent, and his speech inarticulate ; he
had been a long time in this condition when Mr. Bell  saw
him.   His fistula being cured, he recovered gradually by eva-
cuations, blistering on the head, and  a proper regulation of
his diet, so that in a few weeks he was well, returned to his
former  employments, and managed with correctness the af-
fairs of a company.f  Hippocrates mentions a priest, subject
to  annual fits of gout, in  whom the paroxysm terminated re-
gularly for several years in a state of lethargy, from which he
could only be roused to take food  or drink.   It was accom-
panied  by tremors,  stupor, and  forgetfulness,  immobility of
the eyes, and a completely enervated state of the whole body ;
it generally continued one or two weeks.  A man, mentioned
by Willis, at the crisis of a putrid fever, lay for four days in a
 state of profound sleep, from which nothing could rouse him.
He then came out of it after blistering, but his faculties were
gone, so that he knew nobody, remembered nothing, and un-
derstood nothing, " vix supra brutum saperet."  He continued
in this state for  two months, and then gradually recovered.—
 Some years ago I saw a young man, who, at the  end of a te-

    * Mem. Med. Soc. of Lon. vol. ii.    f Bell's Principles of Surgery, vol. ii. 
GENERAL  PATHOLOGY OF  PARALYSIS.       237
dious fever, fell into such a degree of stupor that I apprehend-
ed effusion in the brain. He recovered, however, after a good
many days, and  his bodily health was  soon  restored, but his
mind was in a state approaching to  idiotism.   In this con-
dition he was taken to  the  country, and recovered gradually
after several months.  A most remarkable case of this kind is
related by Dr. Pritchard, on  the authority of the late Dr. Rush,
of Philadelphia.   The patient was an American  student, and
a person of considerable acquirements, who, on his recovery
from fever, was found to have lost all his acquired knowledge.
On recovering his health, he began to apply to  the  Latin
grammar;  had passed  through the  elementary parts, and was
beginning to construe, when one day, in making a strong ef-
fort to recollect a part of his lesson, the whole of his lost im-
pressions suddenly returned to his mind, and he found himself
at once in possession of all the acquirements that he possess-
ed before his illness.
   A state of the mental faculties somewhat  analagous occa-
sionally occurs in diseases of simple exhaustion.  Many years
ago,  I  attended  a lady, who, from  a severe and  neglected
diarrhoea, was reduced to a state of  great weakness, with re-
markable failure of her memory.  She had lost  the recollec-
tion of a particular period, of about ten or twelve years.  She
had formerly lived  in  another  city, and the period of which
she had lost the recollection was that during which she had
lived in Edinburgh.  Her ideas were consistent  with each
other, but they referred to things as they stood before her re-
moval.  She recovered her  health after  a considerable time,
but remained in a state of imbecility resembling the dotage of
old age.
   The state of the brain in such cases as these differs from
apoplexy, but is nearly allied to it;  for a similar condition of
the mental faculties sometimes  occurs  as  a prelude to apo-
plexy, or  it  may be left as a  consequence  of it, after every
other symptom has been removed. A gentleman, mentioned by
 Wepfer,  was seized with hemiplegia of the  right side and
profound sleep; in the second day, the right  side was con-
vulsed, and after this the palsy disappeared.  He  then lay in
 a state of sleep for nine  days, having during  seven of these
been incapable  of taking any food.   On the 8th day he began
to take what was offered, to him, and, on the 9th, he came out
 of the state of stupor, but  his faculties  were gone; he knew 
238
TREATMENT OF APOPLEXY.
nobody, and neither remembered  nor  attended to any thing.
After several weeks he  began to know his more  particular
friends, then began to remember words, to  repeat the Lord's
prayer, and to read a few words of Latin, rather than German,
which was his own language, but only a fev? words at a time.
If he was urged to read  more, he said that he formerly under-
stood these things, but now did not.  He could write, how-
ever, and frequently wrote lines  both  of  German and  Latin
words, in elegant  characters, hut without  meaning.   After
some time he began to pay more attention to what was pass-
ing around him, and to look after his household affairs.   He
often lamented  his want of understanding, and expressed his
hope that he should recover it.   While thus making slight and
gradual progress, he was, after three or four months, cut  off by
an attack of apoplexy.
                      SECTION IV.

       OUTLINE  OF THE TREATMENT  OF  APOPLEXY.

  From the facts which have been related, we have seen rea-
son to believe, that there is a modification of apoplexy which
fatal is without leaving any morbid appearance, and which,
probably, depends upon a deranged condition  of  the circu-
lation in the brain ; we hive also seen grounds for believing,
that  the cases which terminate by effusion  are probably, at
their commencement, in this state of  simple  apoplexy.  We
have seen farther, that we have no certain mark  by  which we
can ascertain the presence of effusion ; and  finally we have
found, that even extensive extravasation  of blood in the brain
may be entirely recovered from  by the  absorption of the co-
agulum.   These considerations give the strongest encourage-
ment to treat the disease in the  most active and persevering
manner.   They teach us, also, not to be influenced  in  our
practice, by the hypothetical distinction of apoplexy into san-
guineous and serous;  and finally, not to  be hasty in conclud-
ing in any particular case, that the disease has passed into a
state in which it is no longer the object of active treatment.
  In the treatment of apoplexy, our remedies  are few  and 
TREATMENT OF APOPLEXY.
239
simple.  Those in which our chief reliance is to be placed are,
large  and repeated bloodletting, active purgatives, and cold
applications to the head, aided by an elevated position of the
body, cool air, and the absence of all  stimuli.   Antimonials
may occasionally be useful as an auxiliary, from their known
effect in restraining vascular action,  provided  in the early
stages they do not occasion vomiting.
   Our first great object  is to take off the impulse of blood
from the arteries of the head by bleeding carried to such an
extent as shall powerfully and decidedly effect the system, and
by^repeating it at short intervals as soon as these  effects begin
to subside. The first bleeding should probably be from the arm,
but, after this, there seems to be an evident advantage in ab-
stracting blood locally, either from the  temporal artery or by
cupping.   Much importance has been attached  by some  to
bleeding from the jugular vein, as  most likely to give  imme-
diate relief to the head; but we must remember, that the only
jugular  vein that can be opened is the external jugular, which
has very little communication with the brain, and consequent-
ly that bleeding  from  it is probably much inferior to bleeding
from the temporal artery.   As soon as possible after the bleed-
ing, means are to be taken for inducing strong purging.  The
most efficient remedy by far for this purpose is the croton oil,
and if the patient cannot swallow, it may be very convenient-
ly introduced into  the  stomach, suspended in  thick gruel or
mucilage, through  an elastic gum tube ; the operation should
be expedited by strong purgative injections.  This is always
to be considered as a most important and leading  point in the
treatment of apoplexy ; and though, in arresting the progress
of the  disease, our first  reliance is  upon large and repeated
bleeding, the first decided improvement of the patient is gene-
 rally under the influence of powerful purging.   The effectual
 application of cold to the head is the third remedy on which
 we rely, and it is equally applicable to the different states of
 the disease, whether arising from simple apoplexy or from ex-
 travasation.  It may be applied either by means of iced wa-
 ter, or  pounded ice in a bladder;  or by a full stream  of cold
 water directed against the crown of the head, and received in
 a basin held under the chin, while the patient is supported in
 a sitting posture.  I have formerly given an example of a pa-
 tient restored in a few minutes or rather seconds by this reme-
 dy from a state  of perfect apoplexy.
   The active use of these remedies is sometimes  followed by 
240
TREATMENT OF APOPLEXY.
a very speedy removal of the apoplectic state.  In other cases,
though little immediate effect may be produced, yet by a per-
severing repetition of them, the coma begins to subside after
some time, perhaps a good many hours, or even several days.
In other cases again, they may be used in the most  active
manner without relieving  the  patient,  and after all we may
find upon dissection, that  the disease was still in the state of
simple apoplexy.  This important fact cannot be too often re-
peated or too carefully kept in mind ; and it should lead us to
prosecute the treatment of every case of  apoplexy with the
utmost vigor and  perseverance.   In one case that occurred
to me, the bleeding was repeated to the extent of upwards of
one hundred ounces, assisted by purging from the  croton oil,
repeated to the extent of above twenty drops, and the case ter-
minated favourably, after  the  symptoms had  continued in  a
very doubtful state for three or four days.
  In the extent  of our  evacuations, indeed, a due regard is
certainly to be had to the age and constitution of the patient,
and the strength of the pulse ;  but I think we  have sufficient
ground for saying, that there are no symptoms which charac-
terize a distinct  class of apoplectic affections, requiring any
important distinction in the treatment; or in other words, a
class, which in their nature do not admit of bloodletting. On
this important point, we may refer with  some confidence to
the facts which have been related.  Weakness of  the  pulse,
and paleness of the countenance, we have seen to be frequent
symptoms of the worst form of  sanguineous apoplexy;  and
on the other hand we have seen  cases terminate by serous ef-
fusion, which were accompanied by strong pulse and flushing
of the countenance.   Finally, we have  seen  one remarkable
case in which there existed every circumstance that could lead
us to consider the disease as serous apoplexy, but which was
fatal without  any effusion; and another  in which  there was
most extensive effusion without any apoplectic symptom.—
It is likewise to be kept in mind, that in apoplectic affections
the strength of the pulse is a very uncertain guide, for nothing
is more common than to find it upon the  first attack of apo-
plexy, weak, languid, and compressible, and becoming strong
and full after the brain has become in some degree relieved by
large bloodletting.
  It would be quite superfluous to detail common  apoplectic
cases treated successfully upon these principles.  But it may
be of use, in connexion with this part of the subject, to select 
TREATMENT OF APOPLEXY.
241
 a few cases, which, occurring in old and infirm people, might
 have been considered either examples of  serous apoplexy, or
 modifications of the disease not admitting of active treatment,
 yet under such treatment terminating favourably.

   Case CXXXVI.—A woman aged 70, of a spare habit, and
 thin and withered aspect, having walked out in her usual health,
 fell down in the  street, speechless and paralytic on the  right
 side.  I saw her four or five hours after the attack.   She was
 then  much  oppressed, but not entirely comatose.    She was
 completely speechless  and paralytic ; her pulse about 96, and
 of tolerable strength.  She was bled to 15 ounces ; purgative
 medicine was ordered, with cold  applications to  her head.
 On the following day she was considerably improved both in
 speech and in the motion of the right  side ; but, having be-
 come rather worse towards night, she was again largely  bled,
 and purgative medicine was continued.  From this time she
 improved rapidly.  At the end of a week she was able to walk
 with little assistance, and in a few days more was restored to
 perfect health.

   Case CXXXVII.—A gentleman aged 70, of a spare and
 feeble  habit, and  very infirm from frequent  attacks of asthma,
 without any warning fell from his chair on the floor in a  state
 of perfect apoplexy, accompanied by violent convulsion. When
 I saw him, an hour after the attack, he was still in a state  of
 perfect coma; the convulsion had recurred at short intervals,
 and had affected chiefly his arms and his face.   His face was
 pale; his  pulse was of good  strength and a  little  frequent.
 He was largely bled from  the arm; and  an active  purgative
 was given, assisted by  a purgative enema, and cold was ap-
 plied to his head.   The convulsions continued for some  time
 to recur with great  violence ; they then became less severe,
 and at length ceased about three hours after the attack, leaving
 him in a state of coma.   But the purgative  having soon  after
 operated freely, he recovered his  recollection.   Next  day, he
 complained of headach, and took more purgative medicine;
 and after a few days more he was in his usual health.

   Case CXXXVIII.—A lady aged  82, on the  morning  of
 Sunday, 8th March, 1818, complained of  headach, but "went
to church.   While in church she lost her recollection, talked
incoherently,  and was brought home  with difficulty, being 
242
TREATMENT OF APOPLEXY,
una*ble to stand.   She was  still incoherent and  partly coma-
tose ;  and when put to bed was seized with violent  convul-
sion, which  affected  chiefly her face and the left side of her
body.  The convulsions recurred  frequently, leaving her  in
the intervals in a state of profound coma, and the left side ap-
peared to  be paralytic.   The pulse was of good strength, and
a little frequent.   She was  bled to 20 ounces ; cold was ap-
plied to her  head, and an active purgative was given as soon
as she could swallow.   On the following day there was little
change ;  more purgative medicine was given.   On  the 10th
the coma was diminished, but it was succeeded by much un-
manageable  restlessness with incoherence and some convul-
sion ; pulse  112.   More purgative  medicine was given; and
small doses  of the tartrate of antimony seemed to be very be-
neficial.   On the 11th there was little change, but on the 12th
she was much improved—began to know her friends, and her
pulse was coming down.   In a few days more she was in her
usual health, and lived for several years.  This  lady had also
suffered an apoplectic attack in 1814.

   Case CXXXIX.—A man aged 70, tall and of a spare ha-
bit, and rather infirm—10th April, 1815—lost his recollection ;
walked unsteadily without  knowing whither he was going,
and could not be  made to comprehend that he  was ill.   He
was put to bed, but insisted upon getting up again, staggered
a few steps, and then fell down on  the  floor in perfect apo-
lexy.   I saw him about an  hour after the attack, when he was
still in a state of profound coma; his pulse a little frequent and
of good strength.  Being bled to 25  ounces, he became  sen-
sible, and took purgative medicine ; and his head was shaved
and blistered.   After three  hours he relapsed into coma.  He
was then'bled again to 15 ounces without any immediate re-
lief, but, the purgative having soon after  begun to opera'te
briskly, he was gradually relieved ; and in a few days was free
from complaint.

   By bloodletting and the other evacuations, we cannot  per-
haps properly be said  to cure apoplexy; we only relieve the
vessels of the brain from the impulse of the general circulation,
and thus  take off one principal impediment to the  recovery,
which consists in the vessels resuming their healthy relations
after this impediment is removed.   But we have every reason
to believe, that these evacuations may be carried as far as they 
TREATMENT OF APOPLEXY.
243
can with propriety, and yet that the vessels may not recover
their healthy action.   Having therefore pushed these evacua-
tions as far as we consider safe or expedient, without relieving
the patient, our next object is to  inquire, what other  means
we have in our power which may contribute to his relief un-
der these circumstances.   Blistering and other external stimu-
lants may perhaps have some effect, and I think I have seen
decided benefit from strong friction of the body, but these  re-
medies are perhaps not much to be relied on.   There are how-
ever two remedies, which have been at different times strongly
contended for in  the treatment of  apoplexy, and which may
come under consideration, at that period or in that condition
of the disease which I have now referred to;  these are, eme-
tics and internal stimulants.  The use of emetics in apoplexy
is as old as the days of Aretaeus, and they have been employed
at different times by physicians of  the first eminence, among
whom  may  be mentioned, Etmuller, Sydenham,  Boerhaave,
and Lieutaud; and the practice must therefore  have some
foundation in observation and experience.   There can be lit-
tle doubt that in the early stage of any apoplectic affection,
the use of an emetic would be a very hazardous practice, and,
at any period of apoplexy  with extravasation of blood, it pro-
bably would be injurious; but in simple apoplexy, after  the
system has been reduced by repeated evacuations as far  as
seems expedient, and yet the coma  has not been removed, it
seems very probable that the action of a mild emetic might be
beneficial.   The delicacy  of the practice, however, consists in
the difficulty of distinguishing simple apoplexy from apoplexy
with extravasation of  blood.  Nearly the same observations
apply to the use of internal stimulants.  We must make   an
important distinction betwixt the action of stimulants in a  vi-
gorous and plethoric state of the system, and their action when
the system  has been reduced by large and repeated evacua-
tions ;  and I think there are conditions of apoplexy in which
stimulants may be used with safety and advantage.
   The observations which have now been made, in regard to
apoplexy, apply equally to the earlier stages of paralysis.   In
regard  to the more advanced cases,  after the immediate effects
of the  attack have been removed, there  are some very inte-
resting  points of  investigation.   Perhaps  we have been too
much in the habit of believing that paralysis of any considera-
ble standing depends upon a fixed and irremediable disease of
the brain.   Many cases are on record  which  tend to shake 
 244            TREATMENT OF APOPLEXY.

 this opinion.   We see recent cases of it completely carried
 off in  a few days; we see others recover more gradually, so
 that, in a few weeks or months, there is no trace of  the  dis-
 ease ;  and in many cases, in which, after long-continued palsy,
 the patient has died  of some other affection, we find  no  mor-
 bid  appearance in the brain, or none adequate to account for
 the disease.   We may add to these facts many singular ex-
 amples of very sudden recovery from palsy even  in  cases of
 long standing.  A  man, mentioned by Dr. Russel,* after an
 apoplectic attack with hemiplegia, recovered the use of his
 arm in six weeks, but the lower extremity remained  perfectly
 paralytic.  After twelve months, in which he made no im-
 provement, he was  one day astonished  to find  that he had
 some  degree of motion of the leg, but it continued only a few
 minutes.  On the same evening he had headach, and in the
 night he was seized witha sort of fit in which the  paralytic
 limb was strongly convulsed, and  after this  he had slight
 power of moving it.   The fit returned next day, and again in
 the night, and then left him completely free from paralysis, and
 in perfect health; he had continued well for eight years at the
 time when the account was written.   A case somewhat simi-
 lar, though of shorter standing, occurred to a friend of mine.
 A middle-aged man was suddenly attacked with hemiplegia
 and loss of speech,  while he was  using violent  exercise in
 walking quick or running; all the usual practice was employ-
 ed without any improvement for a month ; the paralytic limbs
 then became  one day suddenly convulsed, "and when this  sub-
 sided the paralysis was  gone.   In  a woman, mentioned by
 Dr. Home, hemiplegia of considerable standing was  removed
 by an attack of fever, f
   A man whose case is mentioned by Mr. Squire,| had  been
 liable to convulsions from his childhood till he was  twenty-
 three years of age.   The fits then left him, and  he  enjoyed
 good health for three years; when, without any previous com-
 plaint, except a cold, he suddenly lost his speech.   He  had
 no other paralytic symptom, and was otherwise in good health,
but continued perfectly speechless for four years.   He was in
 general a  man of temperate habits, but  having at this  time
been one  evening much intoxicated, he  fell  from his horse
three or four times on his return home, and was at last taken
* London Med. Observ. and Enq. vol. i.   J Home's Clinical Experiments.
             t Philosophical Transactions, vol. xlv. 
TREATMENT OF APOPLEXY.
245
into a house near  the  road and  put  to bed.   He soon  fell
asleep, and had a frightful dream, during which, struggling
with  all  his  might to call out for help, he did call out, and
from that time recovered his speech perfectly.  A young wo-
man, mentioned by Dr. Watson,* had been long liable to se-
vere convulsions, the attacks of which were frequently follow-
ed  by temporary paralysis of  those muscles which had been
most severely affected.  After one attack  she  lost her sight
entirely for five days.   At length, after one of the fits,  she
lost her  speech, and recovered it after a short  time; but the
convulsion returning soon after, was again  followed by loss
of  speech,  and she continued  entirely speechless for four-
teen months.  During this  interval she had no return of the
convulsion, and was otherwise in good health.   Having one
evening violently heated herself by dancing for four hours, she
recovered her speech, and from that time continued free from
complaint.   Several cases still more remarkable are related by
Diemerbroeck.f  A woman, who had been paralytic from the
age of six to forty-four, suddenly recovered the perfect use of
her limbs, when she was very much terrified during a severe
thunder-storm,  and was making violent efforts to escape from
a chamber in which she had  been left alone.   A man, who
had been many years paralytic, recovered in the same manner
when his housfe was on fire;  and another, who had been ill
for  six years, recovered suddenly in a violent paroxysm of
anger.
  A. remarkable case has been communicated to me of a gen-
tleman, who, after an apoplectic attack  lost  his sight, and
continued in  a state of perfect blindness for about seven years.
After that time, while he was  one day out in his carriage, he
suddenly recovered his sight;  and it was found that he had
entirely retained his skill  in drawing, for which he had been
distinguished before  the attack.
  These examples point out a most important principle in re-
gard to paralysis, namely, that cases of it, even  of long stand-
ing, sometimes depend upon a cause which is capable of being
removed entirely, and removed almost in an instant; and they
direct our attention to a most interesting subject of research
in regard to  a  class of affections, which of all diseases  are
usually considered as the most hopeless.
  The restoration  of paralytic  limbs, after the first urgency of

"  Philosophical Transaction?, vol. i.    t Observat. et Curationes Medicse. Obs. X. 
246
TREATMENT OF APOPLEXY.
the attack has been removed, is in many cases entirely a work
of nature,  and seems, in the most common  description of
cases, to depend upon the gradual absorption of the coagulum.
In the treatment of cases of a more  protracted kind,  various
remedies have been employed, chiefly of a stimulating nature,
both external and internal.   To  the former class belong warm
baths, friction, electricity, and galvanism; to the  latter, mus-
tard, ammonia, camphor, and nearly the whole class of stimu-
lants.  All the remedies of this  class, however, must be used
with a considerable degree of caution ; perhaps the use of them
may be more  safe, and may  be  carried on with a greater de-
gree of activity, if the  general system, at the  same time be
kept in a very low state by spare living  and occasional eva-
cuations.   This, I imagine, is always  to be considered as an
essential part of the treatment, and  I cannot agree with some
most respectable writers, who hold  that  the diet in paralytic
cases ought to be nourishing  and restorative.   With this pre-
caution, I think it probable, that there are many cases of pa-
ralysis in which stimulants may be employed with much bene-
fit.  I cannot say what  remedies of this class are to be pre-
ferred.   Some have strongly recommended the tincture of
Cantharides, others have employed  the balsams, turpentine,
mustard, arnica  montana, guaiacum,  seneka,  and  various
others ; also several articles of a narcotic quality,  as the Rhus
toxicotendron, Aconitum  napellus, &c.   In  Germany, phos-
phorus is said to have  been given internally with  advantage;
and the  favorite remedy lately has  been the strichnia.   It is
apt to occasion convulsion, and  the  first proposal of the use
of it as a remedy,  is said to have been founded on the obser-
vation, that when paralytic limbs become convulsed, they fre-
quently soon after recover their power.   In the most favorable
examples, however, that have been given of its efficacy, a long
time was required for  the  recovery;  and as we know that  a
considerable  proportion  of paralytic limbs recover spontane-
ously, we  must receive very  cautiously the  statements in re-
gard to the  efficacy of any particular remedy.   M. Gendrin
states, that he has had extensive experience in the use of the
strichnia, in all its  forms, and the result of his observation is
qertainly not encouraging.   In  all  his cases  it exercised an
immediate and powerful influence,—producing a sense of heat
and formication in the  limbs,  and spasmodic contractions,
which were, in some cases, general, in others confined to the
paralytic limbs.  These effects were continued for weeks, and, 
TREATMENT OF  APOPLEXY.
247
in most of the cases, were repeated several times, but no di-
minution of the palsy was observed in any of them.  Emetics
have been recommended;  also iodine and  mercury pushed to
salivation.   Mr. Wardrop has described  a singular case of
eighteen months standing, which seemed to  derive  benefit
from tickling the  parts with a feather; it recovered  in two
months.   M. Gross mentions a cure by stinging with nettles ;
and Celsus seems to have employed a similar practice.   In
the treatment of paralytic limbs, however, we can expect to
do  nothing, unless the  cause be removed, and their recove-
ry after the cause has been removed, is chiefly to be  regard-
ed  as  the  work of  nature.   As  auxiliaries,  it  is  probable,
that, in general, we can employ nothing better than much dry
friction,  and particularly persevering exercise of the limbs
themselves, as  soon as  they have recovered the slightest de-
gree of motion which shall make them capable of it.*

  * For a variety of important matter relating to the whole subject of apoplexy and
palsy, see the learned work of Dr. Cooke, "on Nervous Diseases and on Palsy. 
APPENDIX
TO
PART   SECOND.
   CONJECTURES IN REGARD TO THE CIRCULATION  IN  THE
                          BRAIN.

   In our preceding investigations on the pathology of apo-
plexy, every attention  has been paid to confine the observa-
tions that were offered, to a direct  induction from  the facts
which were before us.   Nearly connected with these investi-
 gations, however, there are certain views  relating to the cir-
culation in  the brain,  which perhaps may be regarded  as le-
gitimate conjectures.   I  place them in this manner distinct
from the other parts of the  inquiry, because they cannot be
considered as entirely divested of hypothesis.
   When a person previously in  good health falls  down sud-
denly in a state of perfect  apoplexy, and when,  the appro-
priate treatment being promptly applied, this person is speedi-
ly restored to perfect health, it is impossible not to feel the deep
interest of the inquiry,—what the state of the brain was which
produced symptoms of so formidable a kind, and yet was so
speedily and so entirely removed.   If  the patient shall  die
after lying for a considerable time in a state of perfect coma,
and we cannot discover in his  brain the  smallest deviation
from the healthy structure, we feel in no small degree the in-
creasing interest of the inquiry.   It is probable that the source
of these remarkable derangements in the brain, in  as far as it
is within our reach, is to be sought for  in  an interruption of 
ON THE  CIRCULATION IN THE RRAIN.
249
the due relations which ought to exist betwixt the arterial and
venous system of the brain.   On this subject there are certain
principles which appear  to  result from  peculiarities in the
structure of the head, and which do not apply to any  other
organ in the body.
   The facts, on which this investigation is primarily founded,
are derived from the appearance of the brain in animals which
have been bled to death.  While  in such eases  all the  other
organs of the body have been  found completely blanched  or
drained of blood, the brain  has in general presented in this
respect its  usual appearance, and, in some cases, the superfi-
cial cerebral veins  have  even  been found in  so distended a
state, that one writer has proposed the paradox, that animals
which have been bled to death, die of apoplexy.  The most
able and most  satisfactory observations on this subject are
those of the late Dr. Kellie of Lieth,* made upon animals bled
to death under a variety of circumstances.  The brain in most
of these cases, presented its usual appearance, its blood-ves-
sels being  well  filled; while in others, the appearances were
still more remarkable.  In one, the sinuses were loaded with
dark blood, and the vessels of  the pia mater  were delicately
filled with florid Mood.   In  another the sinuses  were loaded
with blood, the veins of the pia  mater were well filled, and
the choroid plexus was remarkably turgid.   In a  very few
only of the examples it is remarked, that the vessels of the
brain contained sensibly less red blood than in the other cases,
and in all of these there was observed  some  serous effusion.
On the other hand, when these  experiments were repeated  on
other animals after a small  opening had been  made in the
cranium by the trephine, the brain was found as much drained
of blood as any other part of  the body.  Dr. Kellie adds to
these experiments, an account of observations  which he  made
along with Dr. Monro, on the brains of two men that  had been
hanged.  On dividing the scalp, in these  cases, the  blood
flowed in such quantities as to afford ample proof of the con-
gestion in the vessels exterior to the cranium, but nothing un-
usual was  observed in the brain.  " The sinuses  contained
blood, but in no extraordinary quantity;  the larger vessels  on
the surface, and betwixt the convolutions, were but moderate-
ly filled, and the  pia mater was, upon the whole, paler and

  * Transactions -of the Medico-Chirurgical Society of Edinburgh, vol. i.  Besides
llie experiments alluded to, I refer to this valuable communication for a variety of
most interesting facts and speculations in regard to the whole of this curious subject. 
250        ON  THE  CIRCULATION  IN THE BRAIN.
less  vascular than we often find it in ordinary cases."—To
these important facts I have only to add another of a very in-
teresting nature, mentioned by M. Gendrin.  With the assis-
tance of M. Beclard, he examined minutely the brains of two
persons who had been put to death by decapitation ; and they
were both greatly astonished  at the turgid state of the cere-
bral  vessels, which they had expected to find empty.
  These remarkable facts lead our attention to certain pecu-
liarities in the structure of the head, to which they may proba-
bly be traced in a very satisfactory manner.  The cranium is
a complete sphere of the bone, which is exactly filled by its
contents, the brain, and by which the brain is closely shut up
from atmospheric  pressure, and from all influence from with-
out  except what is communicated through the blood-vessels
which enter  it.   In an organ so situated,  it is probable, that
the quantity of blood circulating in its vessels cannot be ma-
terially increased, unless something  give way to make room
for the additional quantity, because the cavity is already com-
pletely full;  and it is probable,  that the  quantity cannot be
materially diminished, unless something entered to supply the
space which would become vacant.   In this investigation it
is unnecessary to introduce the question, whether the brain is
compressible, because  we may  safely  assert  that it is not
compressible by any such force as can be conveyed to it from
the  heart through the carotid and vertebral arteries.   Upon
the whole then I think we may assume the position as being
in the highest degree probable, that, in  the ordinary state of
the parts, no material change can take place in the absolute
quantity of blood circulating in the vessels  of the brain.
   But the blood circulating in these vessels must be divided
in a certain ratio betwixt the  arteries and veins of the brain;
and  it is probable that the healthy state of this organ will de-
pend upon the nice adjustment of the circulation  in these two
systems.  If we could suppose a case in which more than the
usual quantity of blood was  accumulated  in the one system,
the  necessary effect  would be a  corresponding diminution in
the other, because the whole mass of blood in the brain must,
by the supposition, remain the same.  Hence would  arise a
derangement of the circulation, such as could not  occur in any
other part of the body, because there is no other organ so situ-
ated as the brain.  We must be cautious, however, of specu-
lating, where it  is difficult to avoid falling into error,  and
must satisfy ourselves with attempting to trace, in a very ge- 
ON THE CIRCULATION  IN  THE  BRAIN.       251
 neral manner, the various ways by which, in such an organ
 as the brain, derangements of circulation may be supposed to
 take place.

   I.  Let us suppose a very plethoric state  of the body, in
 which the general vascular system is loaded with more  than
 the average or healthy quantity of blood.   The arteries going
 to the head will partake  of this general condition, and there
 will be an effort or  impulse which tends to  propel an undue
 quantity of blood into the arteries of the brain.  Though no
 addition to the whole quantity of blood in the brain can actu-
 ally take  place, because the vessels of the brain are already
 full, the constant impulse will be such as tends to introduce
 an additional quantity,  and consequently tends to derange
 the  healthy  relation betwixt the  arterial  and  venous  sys-
 tem ;  for any increase  of  quantity in the one  system  could
 not take place without  any corresponding diminution of the
 quantity in the other.  Let us  say, for example, that the whole
 blood circulating in  the brain is as ten, and  that it is divided
 between the arteries and veins as five to five.   In the loaded
 state of the  system  now referred to, we can suppose a  case,
 in which, by some sudden impulse from  the general circula-
 tion, the arteries of the brain  are, at a particular moment,
 distended by a quantity as six.   In any other part of the  body
 this would be followed by a similar distension of the  corres-
 ponding veins, and the healthy balance of the circulation would
 be speedily restored.  But in  the brain the very reverse would
 happen;  for as  the whole  mass  of  blood must continue as
 ten, if the  arteries were thus distended by a quantity as six,
 the quantity in the veins must be, by the same impulse, dimi-
 nished to four, because the increased capacity in the one system
 of vessels, can  be gained only by an instant  and correspond-
 ing diminution  of capacity in the other.   The result of  the
 condition so produced would be the following.   The arteries
 of the brain would contain a quantity of blood as six, while
 the veins would contain and could transmit a quantity only as
 four.   The  quantity transmitted by the veins would then be
 the measure of  the quantity that could enter the arteries from
, the general circulation, namely, a quantity as four.  But the
 impulse from the general circulation would be such as tended
 to introduce a quantity as six, supposing  the continuance of
 the undue  impulse  from which  the  disease  originated,  or  a
 quantity as  five, supposing the  impulse  to  have subsided to 
252        ON THE CTRCTULATTON  IN  THE  BRAIN.

the state of health.  In either case the impulse would be such
as tended to  introduce a greater  quantity than could enter,
and consequently to keep up the deranged state of the cere-
bral  vessels which had  taken place.   The farther result  of
this would be, an increased flow of  blood into  the external
vessels of the head, producing probably flushing, turgidity of
features, and other marks  of increased determination to the
external parts.   I am aware that this is hypothetical and con-
jectural; but from the nature of the subject, our speculations
respecting it must ever  remain so.  Various facts have been
stated, and  others remain  to  be mentioned, which  give the
conjecture a considerable degree of probability;  and it appears
to be the nearest approach we ean make towards a distinct
conception of that condition to which we give the name  of
eonjestion in the brain.

   II. If there be any considerable interruption to the return
of the blood from the veins of the brain, a derangement will
take place very analogous  to  that supposed under the  former
head.  If the quantity of blood which is actually returned  by
the veins be considerably diminished, there will  be a  corres-
ponding diminution of the qualities which can  enter the arte-
ries.  The healthy impulse from the  general circulation will
then become, in reference to the actual state of the circulation
in the brain in this ease, what  the  undue impulse was in the
other.   But I forbear from urging the inquiry, whether such
a  derangement  as we have now supposed might take place
from causes retarding the return of blood from the head, such
as tumors on the neck, and certain affections of the heart and
lungs; and whether, if it did take place, it might give rise to
symptoms analogous to simple apoplexy.
   Two points, however, may be briefly alluded to in  regard
to the parts of this speculation, referred to under  the two pre-
ceding heads.    (1.)  If such a derangement, as has been sup-
posed, really took place in the vascular system of the brain,
it would follow, that the impetus from the general circulation
would be such as tended to introduce into the arteries  of the
brain a  larger  quantity  of blood  than  could actually  enter.
One  effect of this would be an increased flow of blood into the
external vessels  of the head, and there are various facts which
tend to show that something of this  kind does actually take
place in  the apoplectic attack,—as the flushing of the face,
turgidity of the features, throbbing  of the external vessels, and 
ON THE CIRCULATION IN THE BRAIN.       253
other appearances which have been referred to the doctrine of
determination to the head.   Numerous writers have remarked
the unusual quantity of blood which  is discharged from the
integuments, in opening the heads of persons who have died
of apoplexy.  In some of Dr. Cheyne's dissections, upwards
of a pound was collected in this manner;  and Dr. Kellie made
the same observation on the two men whom he examined after
execution.   Mr.  John Bell  remarks, that having injected the
head  of a  person who died  of an affection of the brain, he
found the  features  so distorted by the injection, the lips  so
protruded,  and  all the  superficial vessels so  much enlarged,
as to make the preparation useless.   The remarkable turgidi-
ty of  the features and of the neck, which  often occurs in a-
poplectic cases, must indeed be familiar to every one; and it
appears to  be most remarkable when the disease has proved
rapidly fatal, without any means having been employed.  A
gentleman  whom I saw with Mr. WTiyte, after some symp-
toms showing an apoplectic tendency, was one morning found
dead  in bed, his body being scarcely cold.  His neck and
features were of  a deep purple colour, and  turgid in a most
uncommon  degree, but no turgidity was observed in the ves-
sels of the brain.   (2.) Upon the  grounds already referred to,
there is reason to believe,  that we cannot, by our evacuations,
diminish in any material  degree the  quantity of blood in the
head.   But if these conjectures shall be considered worthy of
any credit,  it will appear probable, that the effect of our eva-
cuations will be to take off from the cerebral vessels, the ex-
cessive impulse from the general circulation, or even to reduce
it below what would now be considered as a healthy impetus,
and thus to leave the vessels of the brain in a state favourable
for recovering their healthy relations.

  III. A similar derangement might be supposed  to take
place from  causes which directly diminish the capacity of the
venous  system  of the brain.  If a depression  has been pro-
duced  of a portion of bone, so as considerably to encroach
upon the cavity of the cranium, or if a coagulum of blood has
been  deposited, so as to occupy  a considerable space  upon
the surface  of the  brain, the diminution of space  thus produced
would probably affect chiefly or entirely the venous system of
the brain,  the veins being in general more  superficial, and
more immediately exposed to the pressure, than the  arteries.
It would not diminish the  quantity of blood which tends to 
254        ON THE CIRCULATION IN THE BRAIN.

enter the arteries of the head, but it would diminish in pro-
portion to its extent the capacity of the veins, and  thus de-
range the relations  betwixt the  two systems of vessels, in a
different manner from that which has been supposed under the
former heads, but analogous in its effects upon the circulation
of the brain.  When, in the former cases now supposed, the
depressed portion of bone has  been  elevated, the two systems
recover their healthy relations, and the  symptoms disappear.
   It is probable that  a cause of this  kind  may exist in a
smaller degree, in which it shall  not  produce any permanent
interruption of  the  circulation in the brain, but may give rise
to derangement when there is  any occasional  increase of im-
petus in  the circulation.   In the  first part of these essays, I
have described a remarkable case,  in which  a tumor, formed
by deposition betwixt the laminae of the dura mater, occupied
a considerable space on the surface of the brain. The patient had
experienced little inconvenience from it when he was at rest,
but, when in motion, he was liable to attacks  of an apoplectic
nature, from which he recovered in a few minutes.  A gen-
tleman, mentioned  by  Lancisi, who had long suffered from
hemicrania, was seized about the age of 50 with intense pain
in the temple, and soon after had an attack of apoplexy, from
which  he speedily recovered; but  from this time he had an
apoplectic  attack once or twice every month.  This went on
through  the  following  autum  and winter, and he at  last died
suddenly in one of the attacks.   Under the right  side of the
os frontis, the membranes were much thickened, and  connect-
ed with the thickened portion  there was a kind of polypus on
the surface of the brain.  In cases  such as these, it is proba-
ble,  that, when  the circulation is in  a  very tranquil state, or
when the general mass of blood has been reduced  by evacua-
tions, the circulation in the brain goes on in a healthy man-
ner ; but that any  increase of the  quantity of blood, or any
considerable increase of its impetus, leads to the derangement.
It is probable that similar affections might be  traced to causes
diminishing the area of the sinuses, or of the principal veins
of the brain ; and I have formerly mentioned some  remarkable
cases, in which frequent attacks of an apoplectic and  paralytic
nature appeared to be connected with extensive disease of the
arteries of the brain.   Facts  are wanting on this interesting
subject;  but many cases are on record in which an individual
has  suffered in  a few years fifteen or twenty apoplectic attacks,
without  experiencing  in the  intervals  any bad effects from 
ON THE CIRCULATION IN THE BRAIN.        255
them.  Minute attention to such cases may probably lea 1 to
results calculated to throw much light upon the pathology of
apoplexy.

  IV.  There are many interesting facts which lead us to be-
lieve, that the circulation in the  brain may be deranged in  a
manner remarkably different from any of the preceding cases.
Let us suppose that the general volume of blood in the body
is very much diminished.   The effect of this upon each in-
dividual artery is, that its calibre is contracted, and that it acts
upon  the veins with which it  is connected with diminished
momentum.  The arteries of the brain will partake of the ge-
neral state of the system, so that the quantity of blood trans-
mitted to the head will be diminished in the same ratio.  But
while this change is going on, a corresponding accumulation
would probably be taking place in the veins, because the whole
quantity in the head must continue nearly the same.   Upon
this increased mass  of blood  in the veins, the volume in the
arteries would now act with a correspondingly diminished and
inadequate impetus.   It is  probably in  this  manner that there
arises the appearance of congestion in the superficial veins of
the brain, which  have been observed  in animals that have
bled to death ;  and many curious facts occur to us in practice,
which appear to be referable to a derangement of the circula-
tion in the brain, which can  only be  accounted for in this
manner.   I shall relate some of these facts without indulging
farther in speculation.
  A gentleman aged about forty,  had been for  some time
losing considerable quantities of blood by arterial haemorrhage
from the rectum.   Considering it as merely haemorrhoidal, he
paid little attention to it, until his friends became alarmed by
his altered  appearance.   From being strong  and rather ple-
thoric, he had  become weak, exhausted, pale and haggard.
He had anasarca of his  legs,—his  pulse was frequent and
feeble, and much excited by the least exertion.   Along with
these symptoms, he was liable to strong and  irregular action
of the heart,  and complained of  giddiness,  tinnitus aurium,
violent throbbing in the  head,  and frequently of throbbing
headach.   On examining his  rectum, a fungous tumor was
found within the  sphincter, on the apex of which  a small ar-
tery was bleeding per saltum.   This was tied, and there was
no return of the heemorrhage; and under the use of nourish-
ing diet, and a liberal  allowance of wine, all  his other  com- 
256        ON THE CIRCULATION IN THE BRAIN.
plaints disappeared.   He made  up so rapidly in flesh  and
blood, that not long after, apprehensions were entertained that
he was becoming too  plethoric, and  it became necessary to
reduce his regimen, but under these circumstances he had no
return of the symptoms in his head.
  A lady aged twenty-five, had been frequently bled on ac-
count of symptoms in the head which  had supervened upon
an injury.   Considerable relief had followed  each bleeding;
but the symptoms had soon returned so as to lead to a repeti-
tion of the  bleeding  at short intervals,  and  this had been
going  on for several  months.  When  I saw her, she was
stretched upon a couch, her face of the most  death-like pale-
ness, or rather of the  paleness of a stucco figure, her  pulse
very rapid and as small as a thread, her general weakness
extreme.  The mass of blood appeared to be reduced to the
lowest point that was  compatible with life, but  she still com-
plained of frequent headach, violent throbbing in  the  head,
confusion and giddiness.   It  was evident that evacuations
could be carried no farther, and, in consultation with a very
intelligent medical man who  had  the  charge of her, it was
agreed as a  last experiment to make trial  of the opposite sys-
tem, nourishing diet and tonics.   In a fortnight she was re-
stored to very tolerable health.
  Under similar circumstances a friend  of mine  was called
to visit a lady who had suffered from long-continued uterine
haemorrhage.  Her general aspect was that of great exhaus-
tion, but she complained so much of throbbing in the head,
that her medical attendants were treating her  by evacuations
and very spare diet.   She was restored  by nourishment and
wine ;  and as she recovered strength, the feelings in her head
entirely disappeared.
  I have been repeatedly consulted under the following cir-
cumstances.   A gentleman accustomed to very full living, is
seized with  an apoplectic attack, or with symptoms indicating
the  most urgent danger of apoplexy ; he  is saved by bleeding
and other free evacuations, and is kept  for some time upon a
very spare diet  His  complaints are  relieved, and as long as
he keeps quietly at home, he goes on without any uneasy
feeling.  But when he begins to  go abroad, he becomes liable
to attacks of giddiness and confusion, generally accompanied
by palpitation of the heart and an uneasy feeling  about  the
praecordia.   His pulse is now soft  and rather weak, and his
general appearance indicates  the  very  reverse of plethora ; 
           ON  THE  CIRCULATION  IN THE  BRAIN.       257

and these symptoms are removed by a cautious improvement
of his regimen.   This curious fact I have repeatedly had oc-
casion to attend to in the treatment of cases of this kind, and
it has always appeared to me one of very great interest in re-
ference to the pathology of the brain.
  Various other facts will present themselves to the practical
physician, which bear upon this curious subject.  In the last
stage of diseases of exhaustion, patients frequently fall into
a state resembling coma,  a  considerable time  before death,
and while the pulse  can  still be felt distinctly ; and I have
many times seen children  lie for a  day or two in this kind of
stupor, and recover under the use of wine  and  nourishment.
It is often scarcely to be distinguished from the coma which
accompanies  diseases of the  brain.  It attacks them  after
some continuance of exhausting diseases, such as tedious and
neglected diarrhoea ; and the patients lie in a state  of insen-
sibility, the pupils dilated, the eyes open and  insensible, the
face pale, and the pulse feeble.  It may continue for a day or
two, and terminate  favourably, or it may be fatal.  This af-
fection appears to correspond with the apoplexia ex inanitione
of the older writers.  It differs from syncope  in coming  on
gradually, and in continuing a considerable time, perhaps a
day or two ; and it is not, like syncope,  induced by  sudden
and temporary causes, but by  causes of gradual exhaustion
going on for a considerable time.  It differs  from  mere ex-
haustion,  in the complete  abolition of sense and motion,
while the pulse can be felt distinctly, and is in some cases of
tolerable  strength.  I have seen in adults the same affection,
though it is perhaps more uncommon than in children.  A
man considerably advanced in life, in  consequence of a ne-
glected diarrhoea, fell into a state  closely resembling coma ;
his face pale and collapsed, but his pulse of tolerable strength.
An elderly lady from the same cause, had loss of memory and
squinting.  Both these cases recovered by  wine and opiates ;
in the former blistering  on the neck  was also  employed.
Richter states that amaurosis has been produced by haemor-
rhage, cholera, and tedious diarrhoea;  and  he  mentions par-
ticularly a  dropsical  woman,  who became blind when the
fluid was evacuated from her abdomen by tapping.   On this
interesting subject,  I shall at present only add  the  following
remarkable illustration from  an affection of  hearing.  A gen-
tleman, about thirty years of age,  came to  Edinburgh from a
distance for advice in regard to an obscure affection, referred
                            33 
258        ON THE CIRCULATION IN THE BRAIN.
chiefly to the stomach, which had  reduced him to a state of
extreme weakness and emaciation.   As the  debility had ad-
vanced, he had become considerably  deaf, and  when I saw
him he was affected in the following manner.  He was  very
deaf while sitting erect or standing, but, when he  lay hori-
zontally, with his head  very  low, he  heard  perfectly.   If,
when standing, he stooped forward so as to produce flushing
of his face, his hearing was perfect, and, upon raising  him-
self again into the erect posture, he continued to hear dis-
tinctly as long as the flushing  continued ;  as this went  off
the deafness returned.
   Upon the whole, it seems highly probable  that  a certain
balance of the  circulation of the  brain is necessary  for the
healthy condition of its functions ;  that  they are  equally im-
peded by the interruption which takes place in apoplexy, and
the diminished impulse which occurs in syncope  and in many
affections of extreme  exhaustion ;  and that there is a remark-
able  similarity in the symptoms which occur in these opposite
conditions.   What indeed is syncope, but an abolition of sense
and motion?  It is preceded  by  giddiness, tinitus aurium,
and  impaired vision,  and is accompanied by blindness, dilated
pupil, perfect insensibility, and not unfrequently passes  into
convulsion.  It differs then from apoplexy, chiefly or entirely
in the state of the general  circulation, the symptoms accom-
panying the two  affections being remarkably similar, and the
effect upon the sensorial functions almost entirely the same.
   Here however  some questions occur: If the circulation in
the brain be so nicely and peculiarly balanced,  why is it not
seriously deranged by the numerous changes which are con-
stantly occurring amid the variety of circumstances to which
the body  is exposed ?  Why  is not  apoplexy produced by
every increase in the mass of the blood, or why  is it not ex-
cited by every instance of intemperance, violent  exercise, or
strong mental emotion ?  Is there any provision by which the
effects of these  causes  are  averted in their  daily occurrence,
though in a certain condition  of the  system,  each  of  them
may be capable  of producing  perfect apoplexy ?  It seems
probable that there are several circumstances in the anatomy of
the head,  which contribute to this  important end, but I shall
merely allude to them without entering upon the speculations
to which they might lead.   One is, that all the arteries of the
brain enter the head through continued canals of bone. These
appear to  have considerable influence  in arresting any sudden 
           ON THE CIRCULATION  IN  THE  BRAIN.       259

impulse  of blood, and  in directing it off  to  the  external
branches.  Hence the flushing of the face,  turgidity  of the
features, and throbbing of the external vessels, which often
occur in such cases, while no affection  of  the brain follows.
Another circumstance, which seems to contribute to the same
purpose, is the peculiar structure  of the sinuses of the dura
mater.   These at all times must contain a considerable pro-
portion of the venous blood of the brain, and from  their pe-
culiar structure it seems probable that  they are  not liable to
have their area either increased or diminished in any consi-
derable degree.   This remarkable structure must operate very
considerably  in preventing those derangements  of the  circu-
lation which have been referred to. in the  preceding specula-
tions, and which, in an organ situated as the brain is, must
oth^rwisp Kavp toVpn nlace from very slight causes. 
PART  III.
OF THE ORGANIC DISEASES  OF THE BRAIN.
  By organic diseases of the brain we understand, either per-
manent changes of the cerebral substance itself, or new for-
mations within the head.  These  may be either imbedded in
the  substance of the brain, or attached to its surface.  The
principal forms under  which we  meet with these affections
may probably be referred to the following heads:
  I. Tumors formed by the thickening of the membranes of
the  brain, or by deposition of new matter betwixt their lami-
nae.   Of this I have already given a very remarkable exam-
ple, (Case VI.) in which a tumor five inches long, three inches
broad, and half an inch in thickness, was formed in this man-
ner by a  deposition of new matter betwixt the laminae of the
dura mater.
  II. Deposition of a pellucid or semi-pellucid substance hav-
ing the characters of albumen.  This  may  either be formed
in undefined masses under the  membranes of the brain, par-
ticularly under the  arachnoid, as in Case XCIL, or contained
in distinct cysts in various parts of the brain, as in the Cases
XC. and XCI.   The substance which is deposited in these
cases coagulates into  a firm mass  in the heat of boiling water.
It is met with in various degrees of consistency, and there is
some reason to believe that it undergoes remarkable changes
in density,  assuming a firmer texture in  certain stages of its
progress.
  III. A very dense tumor, of a uniform whitish or ash co-
lour, and exhibiting the  appearance  of the properties of coa-
gulated albumen.   This substance is found in distinct round-
ed tumors of various sizes, which are generally attached to the 
            ORGANIC DISEASES OF THE BRAIN.         261

 dura mater, and do not appear to be covered  by any cyst.  I
 have described one which grew on the falx in Case LXXXVIL,
 nearly five inches in circumference, and uniformly white  and
 firm in its consistence; it did not appear to be organized, and
 when analized exhibited the properties of coagulated albumen.
 The remarkable circumstance in this case was, that no urgent
 symptoms  arose from the  presence of this mass until a  few
 weeks before death.  Tumors of this  kind  sometimes  arise
 from the external surface of the dura mater;  in this case  they
 have been frequently known to produce absorption of the bone,
 and to rise  externally under the  integuments of the  head, so
 as to be mistaken for wens.   Many cases of this kind are
 mentioned by the French writers.  In some of them, the dis-
 ease seems to have been  originally excited by injuries;  and
 in others, an injury appears to have accelerated the process by
 which the tumor was making its way through the bone. When
 these tumors have been rashly meddled with by incision, death
 has  generally been the  consequence.   Small tumors, which
 resemble those of this class, are sometimes met with attached
 to the choroid plexus.   I have seen one in each lateral  ven-
 tricle, the size of small hazel-nuts, in a man who died sudden-
 ly after having had repeated epileptic attacks  at long intervals,
 and having been for some time  affected with symptoms threat-
 ening apoplexy.
   IV. Tumors externally resembling those of the former class,
 but internally presenting an organized appearance, and a red-
 dish or flesh-colour, resembling the substance of the kidney.
 These are met with in various situations ; one will be describ-
 ed, the size of an egg, which grew from the tentorium.   The
 two appearances, described under this and the former heads,
 seem to include the most common characters of what may be
 properly called tumors of the brain.   Steatomatous and  fatty
 tumors are likewise described, but they appear to be more un-
 common.
   V.  Tubercular disease.   Of this very frequent  appearance
 several examples have already been given.  It occurs in masses,
 varying in size from the smallest size to that of an egg; and
. these  may be either embedded  in the substance of the brain,
 or attached to the  membranes.   In their earlier stages, they
 present to us a whitish-coloured cheesy matter, generally en-
 closed in a cyst; but, in their more advanced forms, we ge-
 nerally find  them presenting a greater or  less degree of un-
 healthy scrofulous suppuration. 
262        ORGANIC DISEASES OF  THE BRAIN.

   VI.  Induration of the cerebral substance.  Several examples
of this important affection have been already referred to under
the first part of these essays.   I have there stated the grounds
for believing, that it  is the result of  a slow inflammatory ac-
tion ; that it may continue for  a very considerable time in a
state of simple chronic inflammation, and then pass gradually
into a state  of induration :  and, it is probable, that there is in
some cases formed around the diseased portion, a sac of coa-
gulable lymph, giving it the appearance of a new formation
embedded in the substance of the brain.  In the state of sim-
ple induration, this disease may continue for a long time, pro-
ducing urgent symptoms,  and may at length be fatal by pass-
ing into suppuration, or without having suppurated.
   VII.  Ossifications.  Under  this head  are  to be included
both osseous projections from the inner surface of the cranium,
and internal ossifications, which are  commonly found in the
dura mater,  most commonly in the falx.   They generally ap-
pear to be formed of thin laminae of bone in the substance of
the membrane,  and many cases of them are on  record which
did not appear to have produced any symptoms in the brain.
In other cases, however, they seem to produce urgent symp-
toms, especially when they are in the form of sharp spiculae,
or have acute angles which are so situated as to  irritate  the
brain or its  membranes.   In a case of this kind by Saviard,
there was in the broadest part of the falx a small triangular
piece of bone with very sharp   angles; and, where the  dura
mater came  in contact with these angles, it was livid and dis-
charged pus.  In another by La Motte, which was connected
with epilepsy, the bony spiculae were directed against the pia
mater; and  in one by Van  Swieten, there was an irregular
piece of bone an inch long, and half an inch broad, in the sub-
stance  of the cerebellum.
   VIII. Hydatids.   This name has been  applied to  several
affections of the brain, some of which do not  appear to  be
really hydatids.  Of  this kind are the vesicles which are often
met with in  the choroid plexus; they seem to be  merely the
loose celular texture  of that organ, elevated into vesicles by a
watery effusion; and in a case by Dr. Baillie, they could  be
injected from the veins.   Real hydatids, however, do occur in
the brain, as in a case  which will be quoted  from  Zeder, in
which there were numerous hydatids, one of them the size of
an egg, and containing three small hydatids within it.  Cysts
containing a watery fluid likewise occur in various parts of the 
            ORGANIC  DISEASES OF THE  BRAIN.        263

brain ; but it is doubtful whether they are to be considered as
hydatids.   A woman, mentioned by Bonetus, after a blow on
the back of the head, had headach  for a year with constant
vertigo, and  then died apoplectic.  In  the substance of the
left  hemisphere, there was a cyst the size of an egg, which
contained a clear fluid.  In a girl mentioned by the same wri-
ter, who died, on the 12th day, of a febrile disease, which end-
ed in coma, there was found, on separating the two  hemis-
pheres, a cyst which burst on a slight touch, and discharged
limpid fluid to eight or nine ounces.  Bonetus mentions other
cysts of a still larger size,  one especially attached to the nates
and the infundibulum, which burst on taking it out, and dis-
charged fluid to the amount of two pounds.  The patient had
complained of fixed pain in the vertex for four months.   I was
long inclined to doubt the accuracy of these accounts, and to
suppose that, in  such cases, the fluid had really been contain-
ed in .the ventricles, until  I  received, through  my friend  Dr.
Frampton,  the remarkable case  by  Mr. Headington, to  be af-
terwards described, in which a cyst was found in the left ven-
tricle containing sixteen ounces of fluid.
  The affections now briefly described, seem  to include  the
principal modifications of  the organic diseases of the brain.
Others, however, are met with which do not properly belong
to any of these classes, such as  the  stony tumor in a case to
be quoted from Schenkius, the bloody tumor of Rochoux, and
the real fungus haematodes of the brain, of which there  are
some examples on  record.  Fungous protrusion of the cere-
bral substance itself, such  as occurs after  the operation of the
trephine, is occasionally met without any such cause.  A man,
mentioned by Dr. Donald Monro, had a pulsating tumor 'over
the left eyebrow, pressure  on which produced  headach and
giddiness.  It increased in  size, and after seven months  he
died lethargic.   On inspection  the tumor was found to  arise
from the anterior part of the left hemisphere of the brain,' and
to have made its way through the  frontal bone.  It was the
size of a China orange; in its structure it  resembled the me-
dullary substance of the brain;  and it appeared to be covered
by the dura mater.*

  When we endeavour to trace the leading symptoms connected
with these various states of  disease, we do not find any uni-
* Trans. Col. Phy. vol. i. 
264         ORGANIC  DISEASES OF THE  BRAIN.
formity, by which particular symptoms can be distinctly refer-
red  to the various  forms of the morbid affections; we  can
therefore attempt only a  very general outline of the principal
modifications of the symptoms, which are connected with or-
ganic disease of the brain.   They appear to  be chiefly refera-
ble to the following heads.

   I. The first  class is distinguished by long-continued  and
severe headach, without  any other remarkable symptom.  The
pain varies very much both in its seat and in its severity;  and
one very remarkable character of the affection is, that the pain
sometimes occurs in regular paroxysms, leaving intervals of
comparative or complete  relief.   Some remarkable  examples
have already been given of this in Cases LXXXIII. and XC,
and others will be afterwards referred to.  The pain is in some
cases acute and lancinating, in others obtuse; and it is some-
times referred  to  a particular spot, as the crown  of the head,
or the occiput.  In many cases it is accompanied by a violent
throbbing, and this  also may be  general, or it may be referred
to a particular part of the head, as the occiput or one temple.
In the more violent paroxysms the  pain is  intense, obliging
the patient to remain for  a considerable  time in one position,
the slightest motion aggravating it to perfect torture; but the
remissions from this severe suffering are often so remarkable
as to lead a superficial observer into  the belief that it is merely
periodical headach, or headach  connected  with dyspepsia.
This latter supposition  is also  countenanced by the  stomach
being frequently much disordered, and by the more violent at-
tacks being often accompanied by vomiting.   The diagnosis,
indeed,  is sometimes difficult, but, by attention,  it will be
found that the duration and violence of the pain must lead to
a suspicion that the complaint is something more than common
headach, and that, though the stomach is at  times disordered,
yet that the headach is often  most  severe when no  disorder
exists in the stomach that can account for  it.   The patient
generally cannot bear a warm room, the noise of company, or
even the exertion of cheerful conversation, without being  dis-
tressed and his headach  increased;  and the  same effects  are
produced by wine and bodily exertion.  He  seeks  quietness,
coolness, and  darkness;  and in these respects, the disease
differs remarkably from dyspeptic headach, which is common-
ly dissipated by exercise  and cheerful company.   Sometimes
the paroxysms  are accompanied by vomiting, and sometimes 
             ORGANIC DISEASES OF  THE  BRAIN.        265

by violent throbbing  in the head.  If, along with these  local
symptoms, the face be pale and the pulse feeble, and if much
active treatment has been employed without  relief, we  must
suspect the presence of organic disease.   The terminations of
the cases of this first class are various ; they may be suddenly
fatal by convulsion, or more gradually by coma, or by gradual
exhaustion without either coma or convulsion.   A very fre-
quent termination is by the accession of chronic inflammation,
terminating by effusion or otherwise.   In Case  LXXXVII.,I
have given an example in which there was a remarkable mass
of organic  disease attached  to the falx, while  no symptoms
had indicated its existence, until the  occurrence of the symp-
toms of chronic  inflammation a few weeks before death.

   II. In the second  form, after some continuance  of  fixed
headach, the organs of sense became affected,  as the  sight, the
hearing, the  taste  and smell, and occasionally the intellect.
The loss of sight generally takes  place gradually, being  first
obscured, and after some time  lost;  and very often  one eye
is thus affected before the other is at all impaired.   Double
vision also occurs, which either may be  permanent or  occur
at intervals.   One remarkable case will be referred to, in which
the blindness took place rather suddenly, and,  after it had con-
tinued for some  time, sight was  restored under  the action of
an emetic.   It remained distinct for an  hour,  and  then  was
permanently lost.  The intellect is frequently impaired in cases
of this class,  and sometimes the speech is lost.   The morbid
appearances present no uniformity ; in two of them there were
tumors so situated, as directly to compress the  optic nerves ;
in another, a large tumor pressed upon the corpora  quadrige-
mina ; in a  third, the disease was situated at the lower  part
of the anterior lobe; and in an other, in which  the  right eye
only was affected, it was in the substance of the left hemisphere,
near the posterior part.   In a case by Drelincurtius, the  dis-
ease was an enlargement of the pineal gland ; and in another,
in which there were both blindness and deafness, a large  tu-
mor was situated between the brain and the cerebellum.
   III. The third  class corresponds with  the second in the
pain and affections of the senses, with the addition  of parox-
ysms of convulsion.   These may occur with some  degree of
regularity like epilepsy,  or may take place only at particular
periods, when the disease seems to be aggravated,  and to be
*                         34 
266        ORGANIC DISEASES OF THE  BRAIN.
combined with some degree of inflammatory action.   Some-
times the  paroxysms have a resemblance to tetanus, and at
others to slight apoplectic attacks.   A"case  of this kind will
be referred to, in which there was loss of sight, hearing, smell,
and speech, and at last of the power of deglutition.
   The cases of this class present the same varieties of morbid
appearance as the former, and  no peculiar  character can be
traced in them, which  enables us to explain  the diversities of
symptoms  in the three  classes, except in regard to those cases
in which the disease was so situated,  as directly to Compress
the optic nerves.   This seems invariably to produce blindness;
but, in other cases it will appear,, that tumors, corresponding
in  their situation and nearly of similar size, were  in  some
cases accompanied with blindness and convulsion; and in
others by blindness without  convulsion;  and  in others by
pain  alone,  without either of these  affections.   One case
which will be referred to was remarkable, from  the  circum-
stance  that  the • convulsions  ceased  when the lungs be-
came affected, and did not return, the  affections of the lungs
being fatal.

   IV. The fourth class is distinguished by convulsion, with-
out any affection of the senses, often with very little complaint
of pain, and  in  general without that fixed and constant pain
which occurs in the other classes.   The convulsion in some
cases appears tinder the regular form  of epilepsy; in others,
in more  irregular attacks, occurring repeatedly for a short
time, and then  ceasing for  a  considerable interval.  Some-
times violent paroxysms of headach  precede  or accompany
the convulsions, and,  generally, after some  time, the memory
 is  impaired.  The cases of this class may be fatal  in one of
 the attacks of Convulsion, or by coma of some days continu-
 ance.  The morbid appearances are very various.  The most
 remarkable in the cases  to be referred to were, tubercules in
 the cerebellum, an hydatid in the right hemisphere of the brain,
 induration of the pons Varolii or of the substance of  the brain,
 and tumors and bony  spiculsea in various situations.  An im-
 portant variety of the  disease occurs, in which the convulsion
 is confined to one side of the body.   In one case of this kind,
 there was a tumor on  the surface of the opposite hemisphere,
 and  in  another  a portion  of the  opposite hemisphere  was
 indurated; the  former case was also  remarkable   from the 
            ORGANIC  DISEASES  OF THE BRAIN.         267

long  continuation of  the  disease, and  from the weakness
and diminution of size of the lower extremity of the affected
side.

  V.  The fifth class leads our attention to a new set of symp-
toms, namely, the paralytic. These may occur in the form of he-
miplegia, paraplegia, or paralysis of all the parts below the neck,
and in some cases one  limb only is affected.  The disease is
distinguished from the ordinary paralytic cases, by coming on
more  gradually ; one limb, perhaps, or part of a limb, being
first weak, and the weakness extending very gradually, until
it amounts to paralysis.  In  some cases the paralysis is pre-
ceded by violent pain in the limb.  The speech is generally
affected, and in many cases the memory; there may be  fixed
uneasiness in  the  head, or headach occurring in paroxysms.
In one case, there was blindness of one eye; in another, of
both.   In one, there occurred convulsion, but not till an ad-
vanced period; in another, epilepsy  for more than a  year.
The inspections exhibit tumors or  indurations, variously situ-
ated ; in the cases of hemiplegia, on the opposite side of the
brain; in those  of paraplegia, in the cerebellum or tuber an-
nulare.   It  must, however, be  confessed, that the  cases 6f
this class, with paraplegia, are rather unsatisfactory from want
of attention to the condition of the spinal cord.   In several
cases, to be afterwards described, it will be found that though
there was disease in the brain, the real cause of the paraplegia
appeared to be  in the spinal cord ; and, perhaps, it may be
considered as a point not yet ascertained, whether paraplegia
ever arises from disease confined to the brain.

•  VI. The sixth class calls our attention to a subject of much
interest; a train of symptoms which  are referred to the sto-
mach, but which really depend upon disease in the brain.  In
many of the cases of organic disease of the brain, the stomach
is affected;  but those  to which  I  now allude, are remarkable
from  the affection in the  stomach being the prominent symp-
tom.   In these there  is often, through a considerable part of
their  progress, very little complaint of the head, or no com-
plaint so fixed and urgent as to  direct our  attention to the
brain as the seat of the disease.   There is generally, however,
some pain or weight in the head,  sometimes  occurring in pa-
roxysms like periodical headach, or in paroxysms accompanied 
268        ORGANIC DISEASES OF  THE  BRAIN.
by vomiting, like what is commonly called sick headach.  The
pain is increased by exertions, external heat, passions of the
mind, and stimulating liquors; there is generally variable ap-
petite, bad sleep, oppression of the stomach, and frequent vo-
miting.   The vomiting sometimes occurs in the morning, on
first awaking, and sometimes at uncertain intervals, and very
suddenly without  any previous sickness.   There  are, in ge-
neral, uneasy sensations referred to various organs, by which
the nature of the disease may be disguised in its earlier  peri-
ods ; but, after a certain time, symptoms referable to the  head
generally begin to appear, such as fits of loss of recollection,
convulsive paroxysms, and  affections  of sight.   After this
stage of the disease, death may occur suddenly in an attack
of convulsion, or it may be preceded by a train of severe suf-
fering.   In cases of this  class we must beware of being mis-
led in regard to  the nature of the complaint, by observing that
the symptoms in the stomach are  alleviated by a strict  regi-
men, or by treatment directed to the stomach itself.   If diges-
tion be impeded, from whatever cause, the uneasy symptoms
may in this  manner be alleviated; but no inference can be
drawn from this fact, in regard to the cause of  the  derange-
ment.   In the earlier periods of this affection, the diagnosis
is indeed often very difficult.   There is generally more perma-
nent and fixed uneasiness in the head, than we should expect
to find  m a dyspeptic  case, and  the uneasiness is increased
by causes which would probably  be beneficial to a dyspeptic
headach, such as activity and cheerful company.   The promi-
nent morbid  appearances in cases of this class seem to be in
the cerebellum.

   VII. The  seventh  class is distinguished chiefly by slight
and transient affections of an apoplectic character,  of which I
have  formerly given some remarkable  examples.    In  some
cases, it consists chiefly of an habitual giddiness, which makes
the patient afraid to walk alone;  in others, there are sudden
attacks of loss of all muscular power without loss of  recollec-
tion, which are  soon recovered  from.   Sometimes there are
attacks of perfect coma, which may occur at regular or at ir-
regular intervals;  the  patient having, in some cases, such
warning of their approach that he goes to bed before the at-
tack.   There is usually more or less unsteadiness of the limbs,
and generally, but not always, headach.   In some cases there 
ORGANIC DISEASES OF THE BRAIN.         269
 are affections of sight, and these may either be permanent or
 occur in paroxysms ; and  in  some cases, giddiness and loss
 of recollection  are excited by bodily exertion, and go off  on
 desisting from it.

   This  imperfect outline  of  a most  important class of dis-
 eases, I shall illustrate by a selection  of  cases in an Appen-
' dix,  partly from my own  observation, and partly from  other
 authorities.   From  these will appear the  extreme difficulty of
 fixing upon any general principles, or of referring the particu-
 lar character of the symptoms to any  thing in the seat or na-
 ture  of the  disease.  Tumors, for example,  will be found
 under the first class, unaccompanied by any remarkable symp-
 toms ; while, under the other classes, tumors in the same situ-
 ation, and of no larger size, were accompanied by blindness,
 convulsions or paralysis.   It  does  not appear that these di-
 versities depend either upon the size of the tumors, or, as far
 as we know at  present, upon their particular  structure.   But
 these points  remain to be investigated ;  particularly what di-
 versity of symptoms is connected with the nature of the tumors,
 and especially with  their characters, as being tumors distinct
 from the cerebral mass, or as being  indurations of the sub-
 stance of the brain itself.
   In regard to the treatment of this  class of diseases, there is
 little to be said.   I am persuaded, however, that we ought not
 to consider them all as hopeless.   Many of them have certainly
 their origin in inflammatory action, and,  by the proper  treat-
 ment, we have every reason to suppose that their progress may
 at least be impeded, and the life of the patient prolonged, as
 well  as rendered  more  comfortable.   The treatment  will
 consist in  keeping  the  system  extremely  low by evacua-
 tions and  spare diet, cold applications  to the head, issues
 or setons  in  the  neck,  and  avoiding all causes of excite-
 ment.

   I  conclude this part of the subject  with  the  following
 important  case, which I  received from  my friend the late
 Dr. Kellie  of  Leith.   It illustrates, in a very striking  man-
 ner, the  nature  of the symptoms which may exist  with most
 extensive and remarkable organic disease of the brain.

   Case CXL.—A medical gentleman   aged  56,  of a culti-
 vated mind  and temperate habits, had  been  for some time 
270         ORGANIC  DISEASES OF THE BRAIN.
liable to various  ailments, which his medical friends consi-
dered as in a great measure hypochondriacal.  The most de-
fined complaints were occasional uneasiness in the site of the
frontal sinus, and a very peculiar feeling of  numbness in the
point of the thumb.   But his general health appeared good,
and he was able to enter into all the usual enjoyments of life,
having  retired  from practice,  till he was one  day seized,
while walking, with sudden  sickness and faintness.  These
were followed by some headach, and  an  obvious difficulty of
articulation, or  rather a  difficulty in  finding the expression
which he wished to make use of.   He was  now treated by
bleeding and the other usual means ;  but this peculiar loss of
the recollection of words  continued and gradually increased,
so that he had greater and greater  difficulty in recollecting
the words which he meant to employ, but he had no diffi-
culty in pronouncing them.   His understanding, at this time,
was quite entire; his pulse  varying  from 80 to 112.   He
was nearly confined to the house, but out of bed during the
day;  and all the  usual remedies were employed in the most
assiduous manner.  After he  had  gone  on in  this way for
several weeks, he began to have slight distortion of the mouth,
and complained of numbness  of the right arm, and soon after
of weakness of the right leg.   These symptoms gradually in-
creased to perfect hemiplegia; and about this time, also, he
entirely lost his speech.   He was now confined to bed, but
without coma.  He had the perfect use of his sight and hear- *»*
ing, and, as far as could be  judged, his  understanding was
entire.   He died with symptoms of  bronchitis  in  the ninth
week from the first attack.
  Inspection.—The left hemisphere of the brain was found to
be diseased throughout in a  very singular manner.  Some
parts of the mass were indurated, others softened  ; and it pre-
sented a variety of colours, chiefly a rose colour, grey, and yel-
low ;  and the more  diseased  portions were highly vascular.
In some  places  there were distinct insulated masses, enclosed
in vascular cysts; these were generally indurated, but some were
softened, and they were of a rose or flesh-colour passing into
gray.   The change from those parts which retained a natural
appearance to these degenerated portions was  abrupt, and
marked by a rose-coloured line.  These  rose-coloured  por-
tions  were chiefly in  the parts  nearest the  surface; in  the
central parts this passed into the yellow or the grey, and ma-
ny portions were  in a  state of ramollissement.   The whole 
            ORGANIC DISEASES  OF THE BRAIN.         271

left hemisphere,  in  fact,  presented  little else than a mass of
concentric  indurations and softenings of the various colours
which have been mentioned.   On the upper part of the hemi-
sphere, the  disease  did  not extend entirely to  the surface of
the convolutions; but at the base  of the  anterior and mid-
dle lobes it extended to the surface, and at one place there
was a well-defined spot of superficial ulceration the size of a
split pea. 
PART  IV.
OF THE DISEASES OF THE SPINAL CORD AND ITS
                     MEMBRANES.
   In its structure,  the  spinal cord is very analagous to the
brain, except that it is  more dense  in its consistence.   The
membranes of the cord are usually divided into three, the dura-
mater, arachnoid, and pia mater ; but as that which has been
termed  the arachnoid seems rather to be a kind of loose cel-
lular  texture,  scarcely deserving a  distinct name, it will an-
swer  every practical purpose to consider the membranes as
two.

   I.  The dura mater of the cord does not  differ in structure
from that of the brain, except in varying considerably in thick-
ness at  different parts.  The principal facts to be kept in mind
in a practical point of view are, that it  adheres  very slightly
to the canal of the vertebrae by  a very loose  cellular texture,
and that it adheres  very intimately to the margin of the fora-
men magnum.  In  this manner  a cavity is produced betwixt
the membrane and the  canal of  the spine, which may be the
seat of effusion, and which has  no  communication with the
cavity of the cranium ;  on the other hand, the space betwixt
the dura mater and the pia-mater, or the immediate covering
of the cord, communicates freely with the cavity of the cra-
nium, so that a fluid may pass easily from the one to the other,
according to the position of the body.

   II. The pia mater, or proper covering of the cord, is a mem-
brane of a loose or cellular texture.   It seems to be continu-
ous from the pia mater  of the brain, is closely attached  to the 
              DISEASES  OF THE SPINAL  CORD.         273

body of the cord, and furnishes a covering to the nerves which
issue from it.

   III.  The substance of the cord  is firmer than that of the
brain, but in other respects analogous to it;  being distin-
guished into cortical and  medullary matter.   It is divided
into  four columns, the two  anterior of which  take their ori-
gin from the  crura  cerebri, and  the  two posterior from the"
crura cerebelli.   The  spinal nerves arise by two distinct
roots from  one of the anterior, and one  of the posterior  of
these columns ;  and recent investigations have rendered  it
probable, that a diversity of function is concerned in the dou-
ble origin, that is, that  the posterior  columns give origin  to
the nerves of sensation,  and the  anterior to the  nerves of mo-
tion.  A canal has been described in the substance  of the
cord, which is said to be a seat of serous effusion, and to com-
municate with the fourth ventricle.  On the authority of Por-
tal, Senac, Rachetti, and others, we cannot doubt that such a
canal has been observed, but it seems very doubtful whether
it exists in the healthy state of the parts.   In Portal's case, it
extended as far as the fourth dorsal vertebrae, and would have
admitted a common quill. It was full of serous fluid, by which
the ventricles of the brain were likewise distended.

  By the ancients, much importance was attached to the spi-
nal cord in convulsive and  paralytic affections, but their spe-
culations seem to have been in a great  measure conjectural.
A  correct pathology of the  cord appears to be of very modern
date, and perhaps may still be considered as being in a very
imperfect condition.   In attempting a general outline of it, I
shall satisfy myself with a  simple record of the best authen-
ticated facts,  which may be  arranged under  the  following
heads :
   I. Acute inflammation of the membranes, or meningitis  of
the cord.
   II. Inflammation of the body of the cord, terminating by ra-
mollissement or suppuration.
   III.  Serous effusion in the spinal canal.
   IV. Extravasation of blood in the spinal canal, or spinal
apoplexy.
   V. Fungoid disease  and thickening of the membranes.
   VI.  Induration of the cord.
   VII.  Compression  of the cord by new formations within
                            35 
274
MENINGITIS OF THE CORD.
the canal, as tubercles, albuminous depositions, hydatids, and
ossification of the membranes.
   VIII.  Destruction of a portion of the cord.
   IX.  Concussion of the spinal cord.
   X. Certain affections of the bones of the spine-
                       SECTION I.

               MENINGITIS OF  THE  CORD.

  Of this remarkable affection, I am enabled'to give the two
following examples, the second of which I  received from the
late Dr. Duncan.*  The  other I did  not see during the life of
the patient, but I was present at  the examination of the body.
I shall merely relate the cases, without founding upon them
any general conclusions in regard to the characters of the dis-
ease.

  Case  CXLI.—A gentleman aged 26, had been for several
years liable to suppuration of the  left  ear.  It usually dis-
charged  at all times a  little  matter, but the attacks of pain
were followed by more copious discharges ;—the pain on these
occasions extending over the left side of his head, and often
continuing for a week with much severity.   In the first week
of April, 1817,  he was confined from  his usual  employments
by headach, which  affected  both the  forehead and the occi-
put ; he  lay in bed  only part of the  day; his  appetite was
bad, and his sleep disturbed ; but there was little or no fre-
quency of pulse, and for a week the complaint  excited little
attention. About the end of the week, he complained of pain
extending along the neck, and in the  beginning of the second
week the pain in  the head nearly ceased, but the pain in the
neck became more  severe, and  extended farther  downwards
along the spine.  It continued for several days to extend far-
ther and farther down, until at last it fixed with intense seve-
rity at the lower part of the spine, and extended from thence
round  the body, towards the spinous  processes  of the ilia.—
From this time he never complained of his head, and seldom
of the  upper parts of the spine ;  but he became  affected  with 
MENINGITIS  OF THE CORD.
275
great uneasiness over the whole abdomen, and great pain and
difficulty in passing his urine.  From the violence of these com-
plaints, his sufferings about the 15th became extreme ; he could
not lie in bed for five minutes at a time, but was generally walk-
ing about the house in a state of  extreme agitation, grasping
the lower part of his back with both his hands, and knashing
his teeth from  the  intensity of  pain ; he had no interval of
ease, and was sometimes incoherent and unmanageable.—
On  the  16th,  he  went  to  the  warm  bath,  walking down
three stairs, and into an  adjoining street,  with little  assist-
ance.  After  his return from the  bath he thought  himself
somewhat relieved, but the pain soon returned  with its former
severity,  accompanied by great pain in the belly, severe dy-
suria, confusion of thought, and some difficulty of articulation.
The  pulse was about 100, and the bowels were easily kept
open by the ordinary medicines.   On the 17th, the symptoms
were unabated ; his speech was considerably  affected ; there
were convulsive twitches of his  face, and difficulty of swal-
lowing ;  some squinting  also was observed, but it was not
permanent; the pulse was from 120 to 130.   At night he be-
came easier after a bleeding from the  arm,  and lay in bed for
some time.  After  a short time, however, he  got  up again,
and  continued till three o'clock in the morning, sitting up or
walking  about his house, delirious and unmanageable.   About
three o'clock, while sitting in a chair, he suddenly threw his
head backwards with great violence, and immediately fell into
a state of coma, in which he continued for two hours, and then
died.  No paralytic affection had been observed in any period
of the disease, except the slight affection of his speech, no dif-
ficulty  of breathing, no vomiting, and no  convulsion  except
the twitches of the face on the 17th.   The pulse had varied
from 90  to 130, and was reported to have been generally small
and  irregular.   The bowels  were  easily kept open, but  the
pain in the back was much increased by going to stool. Two
days before his death he  had several attacks of  shivering.—
During his illness, much purulent matter had been discharg-
ed from  the left ear, and an inflamed tumor  had formed be-
hind it.
   Inspection.—After the most careful examination, every part
of the brain was found to be in  the most healthy state.   On
takino- out the brain, some  gelatinous  deposition was found
underthe medulla oblongata, and purulent matter appeared in 
276
MENINGITIS OF THE CORD.
considerable quantity, flowing from the spinal canal.   The
spine being entirely laid open, the cord was found with a coat-
ing of purulent matter, which lay betwixt it and its membranes.
The  matter was most abundant at three places;  at the  upper
part  near the foramen magnum,  about the middle of the dor-
sal region, and at the top of the sacrum ; but it was also dis-
tributed over the other parts with much uniformity.   The sub-
stance  of the cord was very  soft, and in some  places much
divided into filaments.  All the other viscera were healthy.

  Case CXLII.—A woman  aged 22, had been for more than
three weeks affected with pains  of a rheumatic  character, ex-
tending over every part of the  body, when, on the 11th of
April,  1820, she was received  into the clinical ward, under
the care of Dr. Duncan.  She then complained of pain in  the
back of the  neck and loins, and at the top of the right scapu-
la ;  also of an acute »pain in the right hypogastric  region, in-
creased by pressure and by inspiration.  The head was con-
siderably retracted, and could not be bent forward; the spine
was  bent backwards, and the muscles of the back felt contract-
ed and rigid.  She had alternate rigors and flushes of heat,
great restlessness;  pulse 148 and full; respiration 44, with
some cough ; tongue foul;  bowels confined.  She was treat-
ed by large bleeding, purging, warm bath, &c.  On the 12th
there was little change.  On the 13th, she  had  difficulty of
swallowing, and great restlessness; the  spine was curved
backwards  as before, and  the  bowels were obstinate, pulse
144.   On the 14th, after free purging was produced, she seem-
ed somewhat relieved, and  could bring her head  a little for-
ward ; but  she said the pain was unabated.   It was now
chiefly referred to the right shoulder, and the upper part of the
chest,  sometimes shooting into the right axilla.  She had also
pain in the lower part of the belly, and  the abdomen felt  dis-
tended and tense.   She had less difficulty of swallowing, and
was  inclined to sleep, but during sleep  there was  much sub-
sultus ; pulse 148 and small.   On the 15th, the head was less
retracted, and there was more power of moving it.   The pains
were abated, except in  the abdomen;  there was  much sub-
sultus  and  tremor; pulse  140; bowels  open; tongue foul.
She  was much inclined to sleep, but quite distinct when roused.
At night she was put into the warm bath, and expired  in  the
bath.  Immediately after death the muscles of the neck  be-
came  entirely relaxed. 
MENINGITIS  OF THE CORD.
277
  Inspection.—There  was some fluid in the ventricles of the
brain ; and, on the posterior edge of the right lobe of the cere-
bellum, there was a thread of coagulable lymph.   The  cervi-
cal  portion of the spinal  cord was healthy; the dorsal  and
lumbar portions were covered by a uniform thin coating of co-
agulable lymph of a greenish-yellow colour,  and  soft  consist-
ence.   It was chiefly on the posterior part,  betwixt the cord
and its membranes, and the membranes were remarkably  vas-
cular.

  Several cases have been described by Duchatelet and Mar-
tinet,  of inflammation of the membranes of the cord terminat-
ing by puriform deposition, but they were in general compli-
cated with a similar disease in  the membranes of the  brain.
The prominent symptoms,  referable to the spinal cord, were,
pain extending along the spine, and tetanic  contraction of the
muscles of the back and neck, in some of them amounting to
perfect opisthotonos.  In one there was  rigidity of the  mus-
cles of the left arm,  with a convulsive twitching  of the thumb
and fingers of both hands ; in another, there  was  a remarkable
slowness of breathing, which was not above five in a minute.
  Ollivier, in his second edition, has described several inter-
esting cases, which present the same general characters.  The
prominent symptom  was,  pain  referred  to  some part  of the
spine, increased by motion, and sometimes little complained of
except upon motion;  it in general extended  along some of the
limbs, and was accompanied by muscular rigidity or tetanic
spasms.   Paralysis occurred in one case, but this seemed  to
depend upon a degree of  ramollissement of the  body  of the
cord.   One of his cases was remarkable from the remissions
of the symptoms in the first stage.   There was an acute  pain
referred to the neck, which came on  with intense severity at
ten o'clock  at night, and ceased at three in  the morning. Af-
ter  seventeen days this ceased, and was succeeded by pain in
the loins, which afterwards extended along  the back and into
the inferior  extremities ; and was then accompanied by mus-
cular rigidity, and tetanic  spasms of the legs, back, and neck.
The patient at last died comatose ; and the case seems to  have
gone on  about five weeks.  There was extensive deposition
of pus and false membrane between the membranes of the cord
at various places, especially in  the lumbar region, where the
matter had found an  outlet betwixt two of  the vertebrae, and
had spread  under the muscles.   In another case, the  pymp- 
278
MENINGITIS OF THE CORD.
toms were, at first, more obscure.  There was an expression
of suffering with retention of urine, but no defined complaint,
except that  the patient  screamed when his lower extremities
were moved, and they became paralyzed without loss of feel-
ing.  There were afterwards rigidity and partial paralysis of
the  arms, rigidity of the trunk, and  retraction of the head;
and he died in ten days.  Between the membranes of the cord
there was an extensive deposition of false membrane and floc-
culent matter, in some places four or five lines in  thickness.
It was most abundant on the posterior surface of the cord,
and towards  its lower extremity;  and there was some soften-
ing of the substance  of the cord.*
   To these  examples of this remarkable disease, I shall  only
add a case mentioned  by Andral.  A woman aged 28, after
sudden cessation of the menstrual discharge, induced by men-
tal agitation, had fever, hysterical symptoms  and vomiting ;
about the fifth day she had retraction of the head, with severe
pain extending along the whole course of  the spine; it was
not affected by pressure, but was increased  to extreme agony
by the least  motion.   She had afterwards difficult breathing
and tetanic symptoms, followed by delirium and insensibility,
and she died on the tenth day.  On inspection there was found
extensive deposition  of purulent  and  flocculent matter, along
the whole course of the spinal cord, which seemed to be con-
tained chiefly in  the  cellular texture  of the arachnoid of the
cord.  The  membranes  of the brain were  deeply injected ;
there was membranous  deposition on some parts, especially
on the right side, also on the tentorium and below the cere-
bellum,—and there was  extensive effusion  of milky fluid  in
the ventricles.
   Inflammation of the parts surrounding the spinal cord may
also be excited by external injuries,  without any affection  of
the bones of the spine.   A  wagoner, mentioned  by  Sir
Charles Bell, sitting  upon the shafts  of his cart,  was  thrown
off by a sudden jerk,  and pitched upon the  back  of his neck
and shoulders.   He  was carried to the Middlesex Hospital,
where he lay for a week, without complaining  of  any thing
except stiffness of the back part of the neck ;  he could move
all his limbs with freedom.   On the 8th day after his  admis-
sion, he was  seized with general convulsions and locked jaw.
After a few hours, he was affected with a singular convulsive

    * Ollivier, Traitd de la Moelle Epiniere et ses Maladies. Tome ii. 16 edit. 
MENINGITIS OF THE CORD.
279
motion of the jaw, which continued in a state of violent  and
incessant motion for about five minutes.   This was followed
by maniacal delirium.   He then sunk into a state  resembling
typhus fever, and,  after four days, was  found to be paralytic
in his lower  extremities.  '• He  lived a week after this, but
continued sinking, and still retained about him much of the
character of typhus.   The  day before  his death, he was per-
fectly sensible, and had recovered sensation in his legs."  On
dissection, a great quantity of purulent matter was found with-
in the spinal canal, which had dropped down to the lower part
of it.   It appeared to have been formed  about the last cervi-
cal  and first dorsal  vertebrae, and  at that place the  interverte-
bral cartilage was destroyed, so that the pus had escaped  out-
wards  among the  muscles.  In  another  case related by Sir
Charles Bell, in which the last dorsal vertebra was - fractured,
purulent matter was found betwixt the spinal cord and its
membranes.   In this case there was no paralysis.   The lead-
ing symptoms were fever, restlessness, vomiting, and high de-
lirium ;  death took place from sudden sinking.*

  To this  place, perhaps, should  be referred  some  notice  of
the appearance of increased vascularity of the cord or its mem-
branes,  and turgidity of vessels about the origin of the nerves.
It constitutes the plethora spinalis of continential writers ; and
much importance has been attached to it as the cause of dis-
ease in  many  of the principal  functions of the body.   By ex-
citing irritation at the origin of the various  spinal nerves, it
has been considered as the source of many obscure affections
of the thorax and abdomen ; of tremor, convulsions, paralytic
affections, chorea, epilepsy, and tetanus.  It has also been re-
garded  as  the seat of many of those painful affections of the
back and the loins, which take place in  connexion with  hae-
morrhoids, menstruation, abortion, and continued fever. These
writers  have  speculated much on the  changes  which  take
place in the thoracic  and abdominal viscera, so as to throw
the blood with undue impulse upon the vessels of the spinal
cord.   Such  determinations they suppose to take place  from
violent colics, suppressed  menstruation, diseases of the liver,
and continued fever.f   It must, however, be  confessed, that

  * Quarterly Reports of Cases of Surgery, part 2.
  +  See Frank, Oratio de Vertebralis Columnse in morbis dignitate, Brera deJla Ra-
chialgite, and Ludwig de Dolore ad Spina* Dorsi.
4 
280
MENINGITIS OF THE  CORD.
the morbid appearances, which are  referable.to  the head of
spinal plethora, are extremely ambiguous ; and there is  little
doubt that they are very much influenced by the position of
the body after death ; but it is due to the speculations of wri-
ters of high eminence, to give an example of the  affections
which they refer to this class.
   (1.) A man who died of peripneumony, had been affected
in the course of his illness with numbness and loss of feeling
in the lower extremities.   On  dissection, the arteries of that
part of the spinal cord,  which is included in the  dorsal verte-
brae, were found turgid with blood, as if they had been highly
injected.* Portal refers to several other cases, which he ex-
plains upon the same principle, and  in which  convulsive and
paralytic affections of  the extremities occurred in various in-
flammatory diseases.
   (2.) An infant was attacked during dentition with convul-
sions, which   degenerated into epileptic  fits.   When he was
five years and a half old,  he had four or five fits  every day,
and became paralytic ;  he died at six years and  a half.   The
spinal sheath appeared  as if injected, and the   mudullary sub-
stance was softened and of yellowish colour about the 6th and
12th dorsal vertebrae.f
   (3.) A young man, aged twenty-one, was affected with fe-
ver and high delirium.   When the delirium subsided, he had
convulsive motions of the superior extremities, and soon after
died comatose.   On dissection, the vessels of the pia  mater
of the spinal  cord, at its upper and posterior part, were found
distended with  blood, as  if they had been  highly injected.
This was especially remarkable about the origin of some of
the spinal nerves.   There  was a similar appearance on the pia
mater of the brain, and some effusion on its surface.^
                       SECTION II.

INFLAMMATION OF THE SUBSTANCE  OF  THE  SPINAL CORD.

  In referring to inflammation of the substance of the cord, the
appearances to be  described under this section, I am guided
by the analogy of the corresponding  affections of the brain.

   * Portal, Cours d'Anatomie Medicale, tom. iii. page 219.
   t Esquirol Bulletin de la Faculty de Medecin*.    X Morgagni, Ep. %, 
INFLAMMATION OF THE SPINAL CORD.       281
 I allude more particularly to the ramollissement, which seems
 to be one of the most common morbid appearances in the acute
 affections of the spinal cord,  and which, in  reference to  the
 brain, I think has been distinctly traced to be a result of  in-
 flammation.  I again leave this doctrine, however, to the judg-
 ment of  the reader, and shall  make no farther use of it here,
 than  as  a  ground of  arrangement.   This important  subject
 has not  yet  been investigated with  that attention which it
 merits; but there  is reason to believe, that  inflammation of
 the substance of the cord, like the corresponding affection of
 the brain, may terminate fatally in four different forms :
  I.  In the inflammatory stage.
  II.  By ramollissement.
  III. By undefined suppuration.
  IV. By  abscess.


 §1.—Inflammation of the substance of the cord fa-
  tal IN THE INFLAMMATORY  STAGE  WITH INCIPIENT RA-
  MOLLISSEMENT.

  This part  of the subject is  obscure, and the termination of
the  disease in the inflammatory stage  may perhaps be con-
sidered as  not ascertained.    It  may, therefore, be  doubted
whether the following  case  can  properly be  referred  to this
head;—it is the  one  most  nearly allied to it, that I find  on
record.
  A woman  had long been subject to  a convulsive affection
in the left lower extremity, immediately before the appearances
of the menses ; this occurred  at every period; when the dis-
charge took  place freely,  it ceased.   After the  cessation   of
the menses, which happened at the age of 40, this extremity
became paralytic.   After  some  time she was affected  with
convulsions of the left arm, and  soon  after  died  comatose.
On dissection, the membranes of the  spinal cord were found
in a state of inflammation at some of the last dorsal vertebrae.
The cord itself was very red and softened on the right side;
on the left it was sound through its whole extent.*   Lieutaud
refers to a case described by Laelius a Fonte,  in which death
happened on the 14th day of continued fever,  after paraplegia
and suppression of urine ;  " in conspectum venit ren sinister,

          * Portal, Cours d'Anatomie  Medical*, tome iv. page 116.
                           36 
282          RAMOLLISSEMENT OF THE CORD.

inflammatus et syderatus;  laesa etiam erat medulla spinalis in
eodem latere."
         § II.—Ramollissement of the  cord.

  This  remarkable  affection will be illustrated by the follow-
ing important cases.   In the first it was complicated with ex-
tensive  inflammation of the membranes; the  second shows
the disease confined to the body of the cord; and the third is
chiefly remarkable from  its resemblance in the symptoms to
an  affection of the  brain.   The  fourth shows the affection
arising from an injury; and the fifth affords a very interesting
example of the  disease in a chronic form.

   Case CXLIII.—A gentleman aged 18,  of an unhealthy
constitution, had  suffered for several  years from ulcers in va-
rious parts of his body, accompanied by exfoliation of bone,
especially from the  leg,  thigh, and sacrum.    For several
months before the fatal attack, he had a sore  on his head with
caries of the bone beneath, to the extent of  a shilling or up-
wards.  But he was in good general health, and was pursuing
his studies at the  University of Edinburgh, when, on the  24th
September, 1823, he consulted  my friend Dr. Hunter, on ac-
count  of  sore throat with slight  fever, which  passed off in
two days; and, on  the  three following days,  he was going
about in his usual health.   On the  30th, he was again  con-
fined to the house, and complained of pain in  his loins with-
out fever.   On the 2d of October, this pain had increased ; it
was chiefly seated among the lower  dorsal vertebrae, and ex-
tended downwards in the course of the ureters, with frequent
desire to pass urine.   On the 3d, the urinary symptoms  were
gone, the pain was diminished in violence, and it was lower
down, being now chiefly referred to the sacrum.  On the 4th,
he continued in the same  state; he was entirely free from fe-
ver ; the  pain  in the back was by no means severe, but  as it
was not removed, a blister was  applied to it.
   (5th.)  The pain  of the back was removed, but he  com-
plained of pain of the belly, especially about  the pubis ;  there
was some dysuria, and a feeling  of numbness on the  inner
side of both thighs.  At night there was retention  of  urine
requiring  the catheter.
   (6th.)  The numbness of the thighs was increased,  with 
RAMOLLISSEMENT OF  THE CORD.          283
acute darting pains occasionally shooting along  them,  and
complete retention of urine.
   (7th.) Perfect  paraplegia of both thighs and legs without
loss of feeling; retention of urine,  and involuntary stools.
The most judicious treatment  had been  employed without
any benefit.
   (8th.) I saw him for the first time along with Dr. Hunter.
There was now perfect paraplegia and  complete  retention of
Urine ; pulse about 90 and soft.   There was some pain, which
was referred to the lower part of the dorsal region ;  there was
no other symptom.   Cupping on the back was  employed,
followed by another large blister, &c.
   (9th, 10th, and 11th.) There was no  change,  except  that
the pulse was becoming a little  frequent.  His  mind was en-
tire.  Some pain of the back was at times mentioned, but it
was not severe, and he  made  no other complaint.  Perfect
 f>alsy of the limbs continued, and the numbness was extend-
 ng upwards upon the abdomen.
   (12th.)  The  numbness was  extending  upon the thorax;
there was very little complaint of the back, but acute darting
pains were complained  of extending along both arms.   The
sore on  the head being  examined, and the opening enlarged,
the bone was found carious, and some matter was discharged
from it by a very small opening.  In consequence of this ap-
pearance, a  perforation was made by a  small head of a tre-
phine, but no disease was found beneath the bone.  In the
evening, his pulse having become more frequent, farther bleed-
ing was employed with relief.
   (13th.)  No  change;  his  mind was  quite entire, and he
made no complaint of any thing;  stools involuntary.
   (14th.)  The  urine came off without the catheter, on raising
him up  into  an erect posture.   Pulse  frequent and  feeble;
strength sinking.  He  died in the  night, having  continued
quite sensible  until about six hours before his death.  There
never had been the  least attempt at motion of the lower ex-
tremities, but the sensibility remained.
   Inspection.—In the brain all was quite sound, except some
old thickening of the dura mater in the neighborhood of the
diseased bone.  The bone was carious  and very thin to the
extent of a half-crown piece ; around this portion it was thick-
ened, especially on one  side, where it was fully double the
natural thickness.   There was  no effusion in the  head, and
no appearance of any recent disease. 
284          RAMOLLISSEMENT OF THE CORD.
   In opening the spinal canal some purulent mater flowed out
during the sawing, from about the middle of the  dorsal re-
gion ; and one of the vertebrae at that place was found conside-
rably carious.   The canal being  opened,  there was found
most extensive deposition of flocculent matter, of a purulent
appearance, on the outside of the membranes  of the cord;  it
was most abundant for some inches  about the lower part  of
the dorsal region, but likewise extended upwards to the fourth
cervical vertebrae.   The  dura  mater  of the cord  being laid
open, bloody sanious fluid was  discharged from beneath it;
and the pia mater was found highly vascular.  The substance
of the cord was found most extensively destroyed in its struc-
ture along nearly the whole extent of the dorsal portion.   The
anterior  columns of this part were  completely disorganized
and broken down  into a soft diffluent pulp; on the posterior
part, the cord was more entire.   When the whole cord was
taken  out and  suspended, it hung together by the posterior
columns of the dorsal portion, while the anterior part of it fell
off entirely in a soft diffluent state.   The parts above and be-
low the diseased portion  were quite firm and healthy.

   Case CXLIV.—A man aged 56, in the last week of March,
1823, was much exposed to cold in travelling on the outside
of a coach, after which he  was seized with pain of the right
arm and leg, most severe about the shoulder, but  affecting
the whole side; and  there was also considerable headach.
He soon perceived some loss of power of the affected limbs,
which  began at the upper part of  the  arm, and  extended
downwards so gradually,  that he was  able to write distinctly,
after he had lost  the power  of raising the arm or bending the
elbow.    The leg then became  affected in the same gradual
manner, and  after  about  ten or twelve days  from  the  com-
mencement of the disease, the whole leg and arm had become
completely paralytic.  Some pain continued in the parts, and
was sometimes severe, especially in the leg.   About this time
he was first seen by Dr.  Moncrieff, who found the pulse 96,
and rather sharp.   He was quite sensible and still complained
of some  headach, and  of pain  extending from the shoulder
along the affected arm and leg.   Repeated bloodletting, blis-
tering, purgatives, &c, were employed, and  the headach was
removed.  The other symptoms continued as before ; the right
leg and arm were  completely paralytic,  and sometimes very
painful;  pulse 84,  and rather weak; his mind quite entire. 
RAMOLLISSEMENT OF  THE CORD.
285
He continued in this state till about the 26th of April, when
the left arm became paralytic rather suddenly; it did not how-
ever become so completely motionless as the limbs of the right
side, and the left leg was not at all affected.   The pulse was
now feeble, and his general appearance expressive of exhaus-
tion.  I saw him first about this time.  There was slight de-
lirium, which however passed off again;  and he continued
quite  sensible and even cheerful, without any pain, except
occasionally in the right leg, till  the  7th  of May, when  he
became again delirious; the pulse 120, and weak.  On the
8th, he lay in a state  of stupor, muttering incoherently, but
answering questions distinctly when he was roused.   He died
on the morning of the 9th, having lost his speech a few hours
before death.   For the last eight or ten days there had been
extensive gangrene on the sacrum.
  Inspection.—Every part of the brain was found in the most
healthy state.  Much  bloody fluid was discharged from the
spinal canal into the cavity of the cranium before the spine was
laid open.   On laying open the  spinal canal, the cord was
found in a state of complete ramollissement, from the second
to the last cervical vertebra; the parts above and below were
quite  healthy.

  The following case shows the  disease running its course
with  much greater  rapidity, and with a different  train of
symptoms.

  Case CXLV.—A boy aged 7, had been  indisposed from
the 18th to the 20th of May, 1823, but so as to  attract little
notice.  There  had been some headach and slight feverish-
ness,  for which he took purgative medicine, and on the morn-
ing of the 22d he seemed almost well.  About two o'clock in
the afternoon of  that day, he was  seized with severe and ge-
neral  convulsions.  I  saw him soon after this, and found him
confused, incoherent,  and  partially comatose; the pulse  60
and weak; face pale; the bowels were slow, and  some worms
had been passed.  The usual remedies were employed with
little effect.
   (23d.) In the  morning he was  partially comatose,  the
eye fixed and insensible.   In  the course  of the day he be-
came less comatose, but incoherent, with  much  talking and
screaming;  complained of headach, and was  impatient of
light.  In the evening there was slight appearance of squint- 
286          RAMOLLISSEMENT OF  THE CORD.
ing, and in the night some convulsions ;  pulse very variable,
being sometimes rapid and sometimes slow;  the bowels were
very obstinate, but yielded to repeated doses of croton oil.
   (24th.) Seemed much better,—eye natural, face pale, pulse
120, bowels kept open by the croton oil.  He was quite sen-
sible, and said there was still some headach, but did not ap-
pear to suffer; he continued in this favourable state until ear-
ly in the morning of the 25th, when the convulsions returned
with much severity, after which he sunk into a low, oppressed
state, and died early in the afternoon.
   Inspection.—There was no  effusion, and no  appearance  of
disease  in the brain.  On removing the brain,  a considerable
quantity of fluid flowed  from the spinal canal;  and on laying
open the canal there was still a good deal found between the
cord and the external membrane.   The cord was healthy at the
cervical portion, but in the upper part of  the dorsal  region it
was remarkably  softened and broken down.   This appearance
extended for  several inches, but varied  in  degree.   At one
place a  complete separation took place in attempting to raise
the  cord,  the part falling down into a soft  diffluent  pulp
through its whole diameter.   From the middle of the dorsal
portion it was quite firm and healthy.  The inner membrane
of the cord was  dark-coloured, highly vascular, and  showed
evident  marks of inflammation, at the part corresponding with
the softened portion of the cord.

   The following case (for which I am indebted to Dr.  Hun-
ter) shows this affection  arising from an external injury, with-
out any affection of the  bones of the spine.

   Case  CXLVI.—A man aged 36, in August, 1827, was
thrown from the  top of a wagon, a height of about  ten feet.
he alighted upon a  pile of small stones, in such a manner,
that the shock, on first coming in contact with  the top of the
pile, was received on his back, between the shoulders.  He
attempted immediately to get up, but fell instantly from com-
plete loss of power of the lower extremities ;  and very soon
after, he had  involuntary discharge of urine  and  faeces.  He
was conveyed home in this state, but little  appears to have
been done for him except the application of sinapisms; and
it was about a month after the accident, when he was received
into the Infirmary of Edinburgh under the care of Dr. Hunter.
He was then  considerably emaciated, and there was complete 
             RAMOLLISSEMENT OF  THE  CORD.         287

loss of motion of the lower extremities, without loss  of feel-
ing, and all the muscles  of the affected  parts were  in a re-
markable state of flaccidity.  He complained of deep-seated
pain on pressure of the region of the  third, fourth, and fifth
dorsal vertebrae.  He had liquid stools, which were discharged
involuntarily.   His urine was at first discharged involuntarily,
mixed  with much viscid mucus;  afterwards it  became  ob-
structed, apparently from the viscidity of the mucus impeding
the passage,and he then required the catheter.  His breathing
was very slow, being generally, when he was asleep, about nine
in a minute ;  and when awake about thirteen.  His pulse  and
other functions were natural; his appetite was moderate,  and
his digestion good ; his mind was quite entire.   On the third
day after his admission, he began to complain of pain in the
temporal and masseter muscles, with  inability  to open the
jaw; and this rapidly increased to perfect trismus.   He then
had  emprosthotonos, and the usual tetanic  symptoms;  the
abdominal  muscles being very tense and hard, and the body
considerably bent forward.   On the following day more ge-
neral spasms took place,  affecting the arms and face, and the
muscles about the neck  and throat, with great difficulty of
swallowing.   The spasms now assumed the form of  opistho-
tonos.   He died in the night, about  forty-eight hours  after
the first appearance of the trismus.    All the usual  remedies had
been employed in the most active and judicious manner with-
out benefit.
   Inspection.—No  injury could be detected  in any of the
bones of the spine.  There was a high degree of vascularity
of the pia  mater of the cord, especially at the upper part of
the dorsal region.  There was most extensive ramollissement
of the body of the cord, which affected  chiefly the anterior
columns.  These were most remarkably softened throughout
almost the  whole course  of the cord, in many places  entirely
diffluent, and the softening was traced quite to the upper part
of the cord, and affected the corpora pyramidalia.   The pos-
terior columns were also softened in many* places, though in a
much smaller degree, not diffluent like the anterior, but break-
ing down under very slight pressure.

   A remarkable modification of the disease occurs, in which,
although it is seated in the upper part of the cord, the symp-
toms appear only in the  superior extremities and  adjoining
organs, without any affection of the lower  parts of the body. 
288          RAMOLLISSEMENT  OF THE  CORD.
A gentleman, mentioned by Ollivier, who  was liable to epi-
lepsy, complained first of uneasiness in the throat, with diffi-
culty of swallowing, accompanied by  an  acute  pain  in the
nape of the neck, and lower part of the occiput, and speedily
followed by fever, difficult breathing and vomiting.  He then
had  numbness of the left hand, which rapidly extended along
the arm ; the right was immediately after affected in the same
manner, and on the following day  they were both  paralytic.
His  legs were not in the least affected, nor the functions of
the  bladder or the bowels.  There was  at last  increase of
dyspnoea with extreme difficulty of swallowing, while nothing
could be seen in the throat, and he died on  the eighth day,
having preserved his intellects to the last.  There was exten-
sive ramollissement of  the upper part of the cord, chiefly
seated in the grey matter, which was of a rose-colour, with a
highly vascular state of  the  membranes connected with the
part; there was extensive effusion in  the spinal canal, and
some extravasated blood  in the cellular tissue between the
vertebrae and the dura mater of the  cord.  The lungs were
dense and loaded with blood, and there was increased vascu-
larity of the bronchial membrane.  In another case, with ex-
tensive ramollissement at the  upper part of  the cervical por-
tion, there was  palsy of all the  extremities.  The only  differ-
ence in the morbid appearances, betwixt the two cases,  seems
to have been, that the ramollissement in the former was chiefly
seated in the grey matter, while in the latter it extended  nearly
through the whole thickness of the cord.   Ollivier has also
described several cases  which  followed a course  similar to
Case CXLV., being fatal in about three  days, with violent
convulsion without paralysis.

   The disease occurs in a more chronic form, in which it may
go on for a considerable time, sometimes for years, before it is
fatal.  There is generally in these  cases some uneasiness in
the back, with paralytic symptoms, beginning in a part of  a
limb, and in a slight degree, and advancing very gradually to
confirmed palsy.  The lower extremities are most commonly
affected, but in  some cases the arms only, and in others all the
limbs.  There is sometimes permanent contraction of the af-
fected limbs, and sometimes there are spasmodic  affections of
them ; and the  disease may go on  in this  manner for years,
and  at last be fatal by ramollissement. 
             RAMOLLISSEMENT OF THE CORD.          289

   This form will be illustrated by the following case, which I
saw along with Dr. Alison.

   Case  CXLVIL—A gentleman aged 42, in October, 1827,
began to be affected with pain in the lower part of the back,
stretching round the abdomen, and  frequently shooting into
the groins.  After a short time this was succeeded by cold-
ness and numbness of his feet, which gradually extended up-
wards with diminished power  of motion,  until, after  several
weeks, it termiqjited in perfect loss  of motion  of both lower
extremities, with retention of urine.   There was pain in some
parts of the affected limbs, and in others a painful sensation
of cold.   This perfect loss  of power continued five  or six
weeks, when after a great deal of treatment by cupping, blis-
tering, &c, he recovered a  slight degree  of motion,  but no
power of the bladder.  He  then began to be  affected with
spasms of the muscles of the back and abdomen, with a very
uneasy  sensation of tightness across the  abdomen,  and at
times across the lower part of the thorax.   The spasms oc-
casionally assumed the character of  opisthotonos, and  at one
time he had almost incessant hiccup, which continued  in a
most violent degree for several days. After the employment of
various antispasmodics, this  subsided under the use of musk.
During the course  of  these symptoms, he frequently com-
plained of pain in various parts of the  spine, at first  in the
lower part, and  afterwards  higher  up ;  and the feeling of
numbness extended  gradually upwards, till it reached nearly
the upper part of the dorsal region, and  was felt in a very
considerable degree along the sides  of the  thorax.
-  After this he became liable to feverish attacks at night, ter-
minating in the morning by  very profuse perspiration, but this
was strictly confined to the parts which were not palsied, and
there never was the smallest  moisture on the lower  extremi-
ties.  He had also, in the upper extremities, a frequent feel-
ing of intense heat, while the lower continued cold  and be-
numbed.  During this time a considerable, but very imperfect,
degree of motion continued  in the lower extremities, but the
bladder continued entirely paralytic.  In April, 1828, he went
to the country, and at this time he had such a degree of mo-
tion as to walk a little on a smooth  garden-walk, leaning on
two persons, or supported by crutches.  But  soon after this
he began to complain of pain in the head.  It occurred in
irregular paroxysms, and was often  referred to a small defined 
290          RAMOLLISSEMENT  OF THE CORD.
spot, on various parts, especially behind the ear,  and some-
times to the tip of the ear.  This pain seemed to abate under the
use of  arsenic ; but soon returned, and became more fixed and
permanent, and the palsy of the limbs  again increased.  After
an absence of about two months, he  returned to town in the
beginning of July.   At this time the headach was severe, and
the power of the limbs so much impaired, that he was entirely
confined to bed.  In a few days after  his return, the right arnt
became paralytic, and his speech considerably impaired. After     i
a day or two, these symptoms rather subsided, but in the fol-
lowing night he became comatose, and died in  the afternoon.
There  never was complete loss of  sensation of the affected
limbs ; he had only complained of it occasionally at particular
spots,  and of a general feeling of numbness and coldness.
   Inspection.—There  were  some  scales  of bone  attached
loosely to the inner surface of the dura  mater  of the  spinal
cord.  The whole cord was  of  a pale rose-colour, and  in a
state of complete ramollissement through  its whole extent,
being in every part entirely diffluent.   The medulla oblongata
was tolerably healthy, except a slight  degree  of softening on
its anterior part;  and there was also a degree of softening on
the tuber annulare,  which seemed to involve the origin of the
fifth nerve.   Beyond this, the  ramollissement became again
more decided, extending along the crura cerebri and cerebelli,
and considerably into the substance of the  brain, at the  part
adjoining the crura.  The brain, in other respects, was healthy,
and there  was no effusion in  the ventricles.           .

   It is difficult to trace the precise nature and progress of the
affection of the cord, when the disease  advances in so  gra-
dual a manner as in this case, and terminates in disorganiza-
tion so complete and extensive.   In tracing the history of the
analogous disease of the brain, we  found reason to believe,
that it is originally  an inflammatory affection of a low chronic
character, seated in a small part of the  cerebral substance ;
that it may  con-tinue for a considerable time in the state of
simple inflammation, and then  subside; or that it may termi-
nate by a  permanent change  in the  structure  of the part, ge-
nerally with some  degree of  induration.   In  this state we
find it when the patient dies of another disease,  as in Case
CXXXV.   When it is itself  the fatal  disease, it seems to be
so by passing either into ramollissement, or into partial and
unhealthy suppuration.   It is probable that the  same  charac- 
             RAMOLLISSEMENT  OF THE CORD.          291

ter of disease takes place in the  spinal cord;  and it is found,
in the same manner, sometimes  in -a state of  ramollissement,
sometimes in the state of induration, and sometimes one part
is*found  indurated and  another  softened.  In a  remarkable
case communicated to Ollivier by Andral, the affection began
with numbness  of the forefinger of the left hand, which gra-
dually extended over the hand and arm.  After some time the
other hand and arm became affected in the same manner, and,
after a year, the lower extremities.   All the  limbs then be-
came paralytic, with permanent contraction but  without loss
of feeling.   The legs were bent upon the thighs, and  the
thighs upon the abdomen, and the arms  rigidly fixed across
the thorax, with the points of the fingers pressed against the
palms of the hands.  If attempts were made to move  the
limbs from these positions, they were thrown  into  spasmodic
contractions with  much pain.  The patient died in this state
at the end of eight years from the commencement of the dis-
ease.  Along nearly the whole length of the cord, there was
a central cavity€ull of a soft grey mucus. It was considered
as arising from ramollissement of the grey central matter of the
cord, and the parietes of the cavity were formed by the white
matter in a healthy state.   In a  case by Ollivier, in which
palsy took place in  the  same  gradual manner, but  affected
only  the lower extremities,  the patient was confined to bed for
seven years.  His legs were  drawn  up  upon  his body,  and
were entirely motionless, but preserved their feeling.   There
was  extensive  ramollissement of the anterior pillars of the
cord: and a very remarkable circumstance was, that the soft-
enino- was greatest in the upper parts of the cord, the corpora
pyramidalia, and several parts of the brain, and became  less
towards the lumbar portion.   The intellectual faculties had
been almost entirely obliterated, but the  motion  of his arms
continued entire to the last.   Such are the difficulties and ob-
scurities cf this interesting subject.
   A  different course of symptoms occurs* in a remarkable case
described by M. Rullier.*   A  gentleman  aged 44, who had
slight curvature of the spine at  the upper part,  was seized
with  pain in the curved portion, which, after several remissions,
increased rapidly, and was  followed by sudden and complete
palsy of both his arms.  They became rigid,  contracted,  and
entirely motionless, and the points of  the fingers  were forced
* Journal de Physiologie, 1823. 
 292          RAMOLLISSEMENT OF  THE  CORD.

 against the palms of the hands.  The sensibility of the parts
 was not impaired, and the lower extremities were  not in the
 least affected, for the patient could walk  about without  diffi-
 culty.  He lived  six years in this state, and died of pectoral
 complaints.   A portion of the cord,  six inches in length, oc-
 cupying two-thirds of the  cervical portion, and part of the
 dorsal, was entirely diffluent, so that  before  the membranes
 were opened, it moved upwards and downwards like a fluid.
 The  posterior roots of the  nerves of this portion  preserved
 their nervous  matter, to their junction with the membranes of
 the cord, but in the anterior roots it was destroyed, and  they
 were reduced to an empty neurilema.  Several other cases are
 mentioned in  the same journal, intended to show the separate
 origin of the nerves of sensation and motion from the different
 parts of the cord.   In one case, there was loss of power of the
 whole body without loss of sensibility, and the disease was in
 the anterior part of the cord.  In another, there was complete
 palsy of the legs, and partial palsy of the arms, while the sen-
 sibility was everywhere morbidly increased.   The  medullary
 matter of the cord was singularly contracted in volume.   The
 anterior part of its upper half was of a reddish-brown  colour,
 and as  it were macerated;  the roots of the nerves inserted
 there were so wasted as to be scarcely discernible,  while  the
 posterior roots were preternaturally large.
   A case mentioned by Ollivier seems to establish the inflam-
 matory origin of  the  ramollissement of the  cord, and  at  the
 same time shows the insiduous and dangerous nature of inju-
 ries  of the spine.  A man  having  suffered an injury of the
 spine by a fall, ten months after the accident had prickling of
 the left lower extremity, which ceased  after  a month, leaving
 it paralytic.  The right lower extremity became affected in the
 same  manner;  and some projection of the vertebrae at the af-
feeted part was thenfirst observed. Hehad afterwards convulsive
 motions of the limbs, and died about  a month after the appear-
 ance of the palsy.   On dissection, there was found false mem-
 brane of an inch in extent, with purulent  matter  betwixt the
 bone and the membranes of the cord  at the affected part;  and
 the portion of the cord included in the diseased membrane was
 entirely diffluent like cream.   Above and below this portion,
 the cord was of a natural consistence, but highly injected, and
 of a deep red colour, especially below the softened part, where
 the redness was intense. 
             RAMOLLISSEMENT  OF THE CORD.          293

   I shall conclude this part of the subject with the  following
 very remarkable case, for which I am indebted to  Dr. Molison.
 I did not see the patient during his life, but was present at the
 latter part of the inspection of the body, when  the spinal cord
 was examined.   I shall simply relate the case, without enter-
 ing upon any of  the very interesting reflections which  might
 naturally arise from it.

   Case CXLVIII.—A street porter aged 37, since February,
 1827, had  frequently complained of pain in his back, and in
 both sides of the thorax, with difficulty of breathing when mak-
 ing any great exertion.   For a month  before his death the
 pain of his back had been more severe, and he had great  dif-
 ficulty of swallowing.  His general health, however, was very
 little impaired ; and  on Monday, 15th July, he carried a bur-
 den to Newhaven, three miles from Edinburgh, and afterwards
 went into the sea to  bathe.  While he was in  the sea, as he
 afterwards  stated, he became very confused, and, on attempt-
 ing to come out, fell among stones.  When he was  taken up,
 he  was  bleeding profusely at  the nose and  mouth; and, after
 he  was  carried to an  adjoining  house, he  vomited  blood in
 large quantities.   Through the  following night he was  rest-
 less and partially  insensible, and talked  incoherently;  he had
 several  attacks which were represented as convulsive, in which
 his  eyes became fixed, and there was much tremulous  motion
 in his legs, but without any motion in his arms, which appear
 to have become paralytic at an early period of the attack. On
 the 16th, he was  first seen by Dr.  Molison: immediately be-
 fore his visit, he  had brought up a large quantity of blood,
 which ran from his mouth in a full stream, and then  coagulat-
 ed.   He was somewhat lethargic, but distinct when roused  ;
 and complained of pain in his head, chest, and bowels.   His
head and his legs were in almost constant motion,  but his arms
were paralytic, being entirely deprived  both of motion  and
feeling.  His  breathing  was easy; his  pulse -frequent  and
 small;  countenance pale and anxious ;  and he had  involun-
tary discharge of urine.   In  the evening, he  again vomited
blood in considerable quantities.   (17th) There  was little
change, except that he recovered the power of the  bladder;
perfect palsy of the arms continued, but  his legs were in al-
most constant motion.  There was no return of the  vomiting
of blood through  the day; at night he fell asleep, and slept
quietly for some' hours, when he awoke quite  sensible ; but, 
 294     UNDEFINED SUPPURATION OF THE  CORD.

 soon after, was seized with vomiting of blood to a great ex-
 tent, and died almost immediately.
   Inspection.—The heart  and lungs were  healthy ;  the  sto-
 mach contained a very large and firm mass of coagulated blood,
 which  entirely filled it, and extended into the duodenum.   In
 the descending aorta, about the 4th and 5th  dorsal vertebrae,
 there was an aneurism the size of an orange, which had burst
 into the  oesophagus  by a  large  opening.   The 3d, 4th, and
 5th dorsal vertebrae were extensively carious  in their  bodies,
 where  the substance  was destroyed to the depth of a quarter of
 an inch.   On opening the spinal canal, some bloody albumi-
 nous-looking matter was found between the bone and  the dura
 mater of the cord, and between the dura and pia mater of the
 cord, there was a considerable quantity of a tenacious,  sanious,
 bloody matter, which covered the surface of the pia mater, from
 about the 2d or 3d to the last dorsal vertebra.   The substance
 of the  cord, from about the 3d to the last dorsal vertebra, was
 of a yellowish colour, and in a state of extensive  ramollisse-
 ment, especially about the centre of this space, where it was
 entirely diffluent.  On removing the cord, the anterior part of
 the spinal canal, viewed from behind, presented several places
 where the bones were denuded of their covering and  carious.
 This was most remarkable about the 3d, 4th, and 5th dorsal
vertebrae.
     § III.—Undefined suppuration of the  cord.

   It may perhaps be doubted, whether some of the cases which
I have referred to this head, ought  not rather to be referable
to the  ramollissement.   These two morbid conditions were
not accurately discriminated till lately; but in the brain there
seems every reason to believe that they are  entirely distinct;
and it is probable that they may likewise be so in the cord.
   1. A womati aged 23, who had suffered  considerably from
syphilis, was seized with severe quotidian intermittent, which
proved very  tedious, and resisted all the usual remedies.  Af-
ter some time, it was accompanied by pain  in the lumbar re-
gion, diarrhoea, tormina, tenesmus, general debility, and ema-
ciation.  About three months after the commencement of the
fever, she began to be affected with weakness and  convulsive
motions of the left lower extremity, resembling chorea. In walk-
ing,  the leg  was dragged, and, if she  attempted, by a  strong 
         undefined suppuration of the cord.      295

effort, a greater degree of motion, it was thrown into  convul-
sive distortions.   Soon  after, the left arm became affected in
the same manner, and there were also convulsive  motions of
the face and eyes.   The complaint in the bowels now ceased,
but the other symptoms increased, and the affection of the
limbs soon amounted to nearly complete paralysis.   She  was
then affected with difficulty of articulation, and  diminution of
memory;  and these  soon terminated in loss of speech, coma,
and death, which was  preceded by general and terrible  con-
vulsions.   Her death happened rather more than a month af-
ter the commencement of the convulsive affection of the leg.
On dissection, some  serous effusion was found  in the thorax,
and in the ventricles of the brain.  The spinal  cord was  soft
and flaccid, and to a considerable extent suppurated.  Its in-
vesting membrane was in many places covered  by a  puriform
fluid;  and there was also serous effusion in the spinal canal.*
   2. A young soldier, who had lately recovered from a pete-
chial fever, was affected with pain in the dorsal vertebrae, dif-
ficulty of moving the lower extremities, retention of urine, in-
voluntary discharge of faeces, general debility and emaciation.
A variety of treatment was employed for several months with-
out relief.  * The weakness of the lower extremities  increased
to perfect paralysis ; and, soon after, the superior extremities
became affected in the same manner.   He then lost his speech,  ,
and, after lying a fortnight in this state, completely immovea-
ble and speechless, but in possession of his intellectual facul-
ties, he died suddenly.   On inspection, there  was  found no
trace of disease in the brain, the thorax, or the abdomen.  The
spinal canal was inundated by a large quantity of sanious fluid.
The cord itself was  suppurated, dissolved,  and  disorganized,
at the  lower part of the dorsal region;  above this, it preserv-
ed its figure, but was very soft.  Its  investing membranes,
and the periosteum lining the canal of the vertebrae, were de-
stroyed at the part where the cord was so much diseased ; but
the vertebrae and their ligaments were sound.*
   3. A man aged 40, was received into the hospital of Crema,
in  the spring of 1804, with no  other complaint than general
weakness and depression, for which no cause could be assign-
ed.  He  lay constantly in bed,  but did not complain of any
pain;  his appetite  was good;  and he was  free from fever.
From  being lean and pale, he became so fat and ruddy that

    * Brera Delia Rachialgite, cenni patalogici. In Atti dell' Accad. Ital. torn. i. 
296
ABSCESS OF  THE CORD.
suspicions were entertained that he was feigning; but as win-
ter approached, he became lean and cachectic.   In February,
1805, he became completely paralytic, both in his legs and
arms;  and he died  suddenly in March.  On  inspection all
was sound in the head, the  thorax, and the abdomen.  In the
spinal canal there was much effusion of bloody, sanious fluid,
with marks  of inflammation and suppuration in the spinal
cord, the substance of which was remarkably soft, and tending
to dissolution.*
                § IV.—Abscess of  the cord.

     A woman aged 56. was affected with sudden loss of power
   of the limbs of the left side, without loss of feeling.   It soon
   amounted to perfect palsy ; her voice became feeble, and her
   speech embarrassed; pulse natural;  respiration quick.  The
   left arm became cedematous.   After  four days  the  speech
   could not be  understood; pulse feeble;  increasing debility;
   stertorous breathing; and she died in a week.
     Inspection.—The  brain was sound, but the pia  mater was
   injected.  In the centre of the right column of thei6pinal cord,
   in the middle of the cervical portion, there was a cavity three
r  inches long,  and two or three lines in  diameter.  It was full
   of a soft matter  like pus, which became  more consistent to-
   wards the parietes of the cavity.  It seemed to be the grey
   substance of the cord converted into pus.   The parietes of the
   cavity were firm, and about a line and a half in thickness, and
   were formed by the healthy white matter.   In the left column
   of the same portion  of the cord  there  was a similar disease,
   but  less extensive, being about one inch long, and one line in
   diameter; and its contents were  less purulent, rather  resem-
   bling ramollissement of the substance of the cord.  The mem-
   branes of the cord were  hardened at the part, and also at a
   part in the dorsal region.f
* Brera, ut stcpra.         f Valpeau Revue Medicale, 1826. 
SEROUS  EFFUSION IN THE  SPINAL CANAL.     297
                      SECTION III.

         SEROUS  EFFUSION IN THE  SPINAL CANAL.

   I  place this appearance by itself, aostaining from any hy-
pothetical speculations in regard  to the origin of it.  I have
already alluded to the ambiguity which attends  serous effusion
when it occurs between the  dura  mater and the  inner mem-
brane of the cord, on account of the free communication which
this space has with the cavity of the cranium, or at least with
the cellular texture of the arachnoid of the brain.   When the
effusion is contained  in  the cavity formed between the dura
mater and the canal of the vertebrae, there can  be no doubt of
its connexion with disease of the spinal canal.

   The following is the most distinctly marked  case of this af-
fection that has occurred to me.

   Case CXLIX.—A strong healthy child, aged nearly two
years, after having been  oppressed and feverish for two days,
was  seized with violent  convulsion.  The first fit continued
about an hour, and left her comatose with distortion of the
eyes.   She had not recovered out of this state when she had
another attack of convulsion,  about two hours after the first.
During the fits, and for some time after them,  there was vio-
lent and irregular action of the heart, and a pecular spasmodic
action of the diaphragm.   The  second fit left her in a  state of
coma from which she never recovered.  She took food or
medicine when they were put into her mouth,  but showed no
other appearance of sensibility.   The eye was completely in-
sensible, and  the  pulse very frequent.   She  had afterwards
several slight attacks of convulsion, and one more severe a short
time before death, which  happened thirty-three hours after the   >
first attack.
   Inspection.—No disease  could be detected in the brain, ex-
cept some appearance of increased vascularity, and slight ef-
fusion under the arachnoid.  The brain and cerebellum being
removed, there was a copious  discharge of bloody fluid from
the spinal canal.   The canal being laid open, there was found
                            38 
298     SEROUS EFFUSION IN THE SPINAL  CANAL.

a copious deposition of colourless fluid, of  a gelatinous ap-
pearance, betwixt the canal of the vertebrae and the dura mater
of the cord.   It was most abundant in the cervical and upper
part of  the  dorsal regions.   Between  the membranes of the
cord there remained a small quantity of the bloody fluid which
had flowed into the cavity of the cranium.  The substance of
the cord, at the  upper part, seemed softer than natural, and
very easily torn.  All  the viscera of the  thorax and abdomen
were perfectly healthy.  The  foramen ovale was pervious by
a small opening.
   The effusion on the  outside of the dura mater, in this case,
was fairly to be considered as a  distinct  disease of the spinal
canal;  but the other effusion between the membranes, though
somewhat more ambiguous, is not to be  overlooked, especial-
ly if we should find that this fluid is bloody, while the effusion
under the arachnoid of the brain is colourless.

   In a child, aged between 3 and 4 years, mentioned by Ol-
livier, who died with symptoms of opisthotonos, difficult deglu-
tition, and coma, he found deposition of a red and very con-
sistent fluid, in the cellular texture between  the dura mater of
the cord and the  canal of the vertebrae  in the  dorsal region,
 serosity within the membranes, and the arachnoid of the cord
 covered with an albuminous concretion for four inches.

   The following cases are given by the eminent writers whose
 names are annexed to them,  as examples of diseases depend-
 ing upon serous effusion within the spinal canal.

   1. Morgagni mentions a man aged  40,  who was affected
 with acute  pain and weight in the  lower dorsal vertebrae, the
 pain occasionally extending upwards or downwards to the top
 and bottom of the spine.  After eleven days  he was seized
 with paralysis of the right lower extremity, and in three  days
 more with retention of urine.   The pain was now so acute as
 to prevent him from  lying down, and was  soon after accom-
 panied by  dispnoea, vomiting, and tonic convulsions of the
 trunk and arms, which recurred at intervals, and continued for
 about fifteen minutes.   The left inferior extremity then became
 paralytic, and he died suddenly; his intellectual faculties had
 continued entire, except during the paroxysms  of convulsion.
 On inspection much fluid was found in the cavity of the spine, 
SPINAL APOPLEXV.
299
but the cord was sound ;  there was  also fluid  on the surface
of the brain, but none in the ventricles.*
   2. A  child aged twelve months, whose case is briefly re-
lated  by Mr. Chevalier, after appearing to be in much pain,
lost the  use of the  inferior extremities, and died in three days.
The spinal canal was found full of bloody serum.f
   3. Bonetus mentions a young woman, who, after suffering
severely from colic, fell into  paralysis.  It began at the up-
per part of the  arms, and extended gradually to  the points of
the fingers.  Afterwards  the legs  became affected, and she
died of gradual exhaustion a year after the first appearance of
paralysis.  Through the whole extent of the spinal cord, there
was a space  betwixt its dura and  pia mater, full  of serous
fluid.   There was also some effusion on the brain.:):
   4.  A man, mentioned  by Portal, had numbness of the infe-
rior extremities, followed by paralysis of them, and extensive
oedema.   After  some time  the  arms became affected in the
same  manner, and the oedema extended over the whole body.
He died comatose.  On inspection much fluid was found both
in the brain  and in the spinal  canal.   In  the  centre of the
spinal cord there was a canal into which a large writing quill
could be introduced.   It was full of serous fluid, and extend-
ed as far as the third dorsal vertebra.
                      SECTION IV.

SPINAL APOPLEXY, OR EXTRAVASATION  OF BLOOD  IN  THE
                     SPINAL  CANAL.

  Case CL.—A child  aged 7  days,  1st  September, 1818,
was  observed not to  suck, and  appeared as if he were pre-
vented by something which impeded the motion of his tongue.
Throuo-h the following  day he cried frequently, and still did
not suck; in the evening he was seen  by Mr. White, who
found the jaw clenched by  spasm, but by  very little force  it
could be opened.  On the third day he was seized with con-

         *Mor"-a<mi de Causis et Sedibus, &c. Epis. 10. Sect. 13.
   t Med. Chir. TraiiS. vol. iii.     I Boned Sepulchretum Anatomicum, torn. i. 
300
SPINAL APOPLEXY.
vulsion, which recurred at various intervals, sometimes in the
form of tonic spasm of the whole body, and sometimes of vio-
lent convulsive agitation.   On the fourth the  convulsion con-
tinued, and  he died in the afternoon.
  Inspection.—No disease could be detected in the brain.   In
the spinal canal, there was found a long and very firm coagu-
lum of blood, lying between the bones and the membranes of
the cord on the posterior part, and extending the whole length
of the cervical portion.

  This  is the only case that has  occurred to me of this re-
markable  affection; but, as it appears to be  uncommon, and
to present some very interesting phenomena,  I am induced to
add the following examples.
   1. A lady aged 40, had headach and pain of the back;
after a few days the pain of the back became very acute, and
violent  convulsion took place, which was fatal, after continu-
ing five or  six hours.  All was sound in the brain, but ex-
tensive extravasation  of blood was  found in the spinal canal,
which was most abundant about the seat of the pain.*
  2. A gentleman aged 61, had just arrived  in Paris from  a
long journey, when he complained of pain of his  back, ex-
tending from the cervical vertebrae quite to the sacrum.   Af-
ter a few hours he was seized with  paraplegia, and inconti-
nence of urine and faeces; and he died while the  physician
was  talking  to him, who had been sent for on the occurrence
of the palsy.  There was extensive extravasation of blood in
the spinal canal, under the membranes of the cord.  At the
lower part it formed a mass like a bouillie of bullock's  blood,
in which the substance of the cord could not be distinguished,
as far as the third dorsal vertebra;  and above this, where the
cord was entire, it was of a deep red colour, and very soft.f
  3. A young lady aged  14, had headach and  pain in the
back, with a tendency to sickness on sitting up.   At the end
of a week there was a sudden and violent aggravation of this
pain, followed by general convulsions, which were fatal in five
or six hours.  The spinal canal was found filled with extrava-
sated blood, in the lumbar region, which had  been the seat of
the pain.  The brain  and all the other viscera were  sound4
  4. A miller, in lifting a heavy sack, suddenly  lost the use

   * Ollivier, ut supra.   + M. Gaultier de Claubry, Jour. Gen. de Med. 1808.
                f Chevalier, Med. Chir. Trans, vol. iii. 
SPINAL  APOPLEXY.
301
of his lower extremities, and died in fifteen days.   Extrava-
sated blood was found, mixed with sanious matter, in trfe spi-
nal canal.  The membranes were inflamed, and the nerves of
the cauda equina  appeared rotten, as  if they had  been long
macerated in putrid water.*
   5.  A gentleman died of a disease which  was  considered
as apoplectic, but in which he retained his mental  faculties to
the last.   No disease was discovered in  the brain, but there
was a great quantity of extravasated blood in the spinal canal.f
   6. A man  received a violent blow on the three inferior lum-
bar vertebrae, by a log of wood which fell upon him ; he died
in four hours.  Extravasated blood was  found in the spinal
canal, but the vertebrae were entire, and the cord was healthy.I
   7. A boy aged 14, received a violent jerk of his neck by a
cord which was thrown oyer his head as he was swinging for-
ward in a swing.   He felt no bad effect at the time, but, after
some time, became inactive and weak in the limbs, with stiff-
ness of the neck, and difficulty of moving his  head.   Nine
months after the accident the weakness of his limbs increased to
paraplegia;  and soon after he had paralysis of the  arms, with
retention of urine.   He had been  a  short  time  in this state
when he was seized  with violent pain in the spine; he then
had difficult  and quick breathing, wThich was first observed
during sleep, but afterwards continued while he  was awake;
and he died after suffering severely from it for two days.  His
death happened about ten months from the injury, and a few
days after the violent attack of pain  in the spine.  A large
quantity of extravasated blood was found in the spinal canal,
betwixt the  bone and the  theca  vertebralis.   It  was partly
coagulated, and partly fluid, and appeared to have come from
the upper part of the canal, about the second or third cervical
vertebra.§
   The following  very remarkable  case is mentioned by Dr.
Bright,  and was communicated  to him by Dr.  Stroud.   It
affords the only example that I find on record of the regular
apoplectic cyst connected with  the  cord,  analogous to  that
affection as it is found in the brain.
   A gentleman aged 48, who had suffered long  and severely
from rheumatism, about a year before his death had an attack
of hemiplegia,  from the  effects of which  he never entirely

                      * Chevalier, ut supra.
    t Dm Hamel, Reg. Scient. Acad, Histor. An. 1683. Sec. 5, cap. 2, p. 254.
 J Morgagni, Epis. 54.  § Howship's Observ. in Surgery and Morbid Anatomy, p. 115. 
302
FUNGUS OF.THE CORD.
recovered.   The palsy, which at first was  hemiplegia  of the
left side, gradually changed into paraplegia, and  he had se-
veral minor attacks, characterized by pain in the  head, back,
and limbs, with feverishness.  For two months before death
the palsy rapidly increased;—when it reached the. trunk he
had retention of urine and sloughing of the nates ;  and during
the last thirty-six hours of his life he gradually lost the power
of speech and swallowing, and his  mental  faculties.  There
was no disease in the brain except a little serous  effusion be-
tween  the membranes.  The cord  itself was sound, but its
membranes exhibited traces of inflammatory action, and there
was between them considerable effusion of a reddish, serous
fluid.  At the upper dorsal vertebrae,  on  the left side, there
was an apoplectic cyst,  more than an  inch in  length, and
about half an inch in diameter,—it was external to the cord,
and contained the red and broken remains of a  coagulum.
The coagulum seemed to  be contained in an  adventitious
membrane, under the pia mater of the cord.
                      SECTION V.

THICKENING AND FUNGOID DISEASE  OF THE MEMBRANES OF
      THE  CORD,  AND  FUNGUS OF THE CORD ITSELF.

  1. The Count de  Lordat, aged 35, received an injury of
the  neck by being overturned in his coach  from a  high and
steep bank.   He felt at the time only some pain in his neck,
which  went  off in a few  days.   Six months after, he had
weakness of  the left  arm, and  some difficulty of articulation,
and these symptoms  continued stationary for nearly  twelve
months.  They then  increased, the  arm becoming' withered
and useless, and his  speech nearly lost, and he had involun-
tary convulsive motions of the whole body.   After  another
long interval, his right arm became benumbed ; he was also
seized with dispncea and  difficulty  of swallowing, and his
body was much emaciated.  His bowels were loose ; his uri-
nary functions were natural.  His death happened suddenly,
nearly four years after the accident.   His intellectual faculties
had remained entire; his  lower extremities had  been for  a 
FUNGUS OF  THE  CORD.
303
considerable time weak and unsteady, but not entirely paraly-
tic, for he could walk from one room to another, leaning on a
man's arm, a few hours before  his  death.   The spinal cord
included in the cervical vertebrae was  found remarkably firm,
and the membranes of this portion were so dense, that  there
was great difficulty in cutting through  them.   The medulla
oblongata appeared one-third larger  than natural.   The pia
mater was thickened, and, toward the falx, there was some
appearance of suppuration ; the ventricles were full of water.
The lingual and  brachial nerves,  at  their origin, were very
compact or nearly tendinous.  This hardness was found, in the
cervical nerves,  to be owing to the density of the membrane
covering them.*
   2. A young man aged 14, fell from a window in the second
story of a house into the street.   His back was much bruised,
but without fracture;  and he  afterwards continued to walk
with his body bent considerably forwards.  After three years
and a  half, he  was seized  with violent pain  in  the  back,
thighs and legs ;  and a tumor began  to form over the lumbar
vertebrae, which increased gradually till it attained to a very
great size.  The prominent part of it  was red, and repeated
attacks of haemorrhage took  place from the apex  of the  tu-
mor.   He was then affected with complete paraplegia, incon-
tinence of urine and faeces, and extreme  emaciation;  and at
length died gradually exhausted, about six years after the ac-
cident.   On dissection, the tumor was  found to consist of a
large fungous mass resembling the medullary substance of the
brain, which took its origin from the  spinal cord, and had ex-
tended itself upwards and downwards, from the third dorsal
vertebra to the coccyx.   Many of the  vertebrae, both dorsal
and lumbar, were extensively carious  on the  posterior part,
and some of the  lumbar  vertebrae had  nearly disappeared.
There was a general softening  of all  the bones  of  the spine
and of the sacrum and ilium.f
   3.  A man aged 20, in the beginning of 1815, had first im-
paired digestion, then difficult breathing and palpitation ; and,
in the end of April, he had  anasarca of the  legs, and such
strong and extended pulsation  of the heart, as  left no  doubt
of'the  existence  of dilatation and  hypertrophia of  the  left
cavities of the heart.  He was relieved by diuretics, and con-
tinued better till May, when  he had pain, tenderness, and dis-
* London Medical Observations and Inquiries, vol, iii.
\ New London Med. Journal for 17D2. 
304
FUNGUS OF  THE  CORD.
tension of the abdomen.   After free evacuation of the bowels,
these symptoms subsided, and,  about the 18th  May, it  was
first observed that he had weakness in the lower extremities,
without diminution  of  sensibility.   All  the  other  symptoms
now disappeared.   On the 20th of May, the paraplegia  was
complete, with retention  of urine ; and he now, for  the  first
time, complained of pain in  the loins.   There  was still no
diminution of  sensibility, but, on the contrary, the  limbs,
when moved, were extremely painful.  His digestion was  now
good, his breathing easy, the action of the heart natural,  and
his mind entire ; and he  continued in this state till the 22d of
July, when the paralytic  limbs became insensible.  Gangrene
then took place on the sacrum, and he died  on the 10th of
August.
   Inspection.—The bodies of the third, fourth, and  fifth  cer-
vical vertebrae were  unequal and  slightly softened, and  the
anterior ligament was destroyed.   The outer membrane of the
cord at this place had degenerated into a thick, fungous tuber-
cular mass,  of the  firmness of the pulmonary tubercles  not
suppurated, and of  a greenish-yellow colour.  This mass ex-
tended one decimetre and five  millimetres in length,  and four
millimetres in breadth, and involved in it the ganglions of the
seventh cervical and three first dorsal nerves.   The portion of
the cord  covered by this mass was in a  state of ramollisse-
ment, which  affected chiefly  the anterior columns ;  but the
posterior columns were also slightly  softened,  in a space cor-
responding to the  three  upper dorsal  vertebrae.  The brain
was sound, except a small tubercle in the right  hemisphere ;
the heart was quite sound, and  the lungs, except  one small
tubercle, not  softened.   In the  abdomen there  were adhesions
and some puriform fluid.*
   Fungoid disease of the dura  mater of the  cord is also  met
with in connexion with disease  of the vertebrae ;  several cases
of this kind are related by Ollivier.   Dr.  Bright has described
a case of paraplegia of five years standing, in which a portion
of the cord had degenerated into a soft translucent jelly  of a
reddish  purple colour.   From  the portion  which was  thus
chiefly degenerated, in the middle of the dorsal region, the
substance of  the cord formed a canal, tapering upwards  and
downwards, filled with a watery jelly.  There was also some
scrofulous tubercular matter at the portion principally diseased.
* Serres Anat. Comp. de Cerveau, torn. ii. p. 234. 
COMPRESSION OF THE  SPINAL CORD.        305
                      SECTION VI.

             INDURATION  OF THE SPINAL CORD.

   This part of the pathology of the cord is exemplified in the
 remarkable case of the Marquis  de Causan.   His complaint
 began with  a prickling in the fingers  and toes of  the right
 side, which extended gradually upwards along the  arm and
 leg :  the parts wasted, became  cold, and  lost their feeling ;
 but they retained such a degree of motion, that he could walk
 with the assistance of a crutch under the arm of the affected
 side.   He had continued in this  state more than a year, when
 the left side became affected in the same manner.   He was
 then confined to bed,  and  incapable of any motion, either  of
 the trunk or  extremities, the other functions continuing for
 some time in a healthy state.  His sight  and hearing were
 next affected, being first weakened, and gradually destroyed.
 In the same gradual manner he lost his speech and the power
 of swallowing; and soon  after this he died.   The pulse and
 breathing had continued natural until a short time before death,
 when both became remarkably slow ; the pulse being from 30
 to 40 in a minute.   On dissection the brain  and all the vis-
cera were found  in the most healthy state.   That part of the
spinal cord which is included in the cervical  vertebrae was so
hard as to have the consistence  of cartilage ;  and the mem-
branes of this portion were red as if inflamed.*
                      SECTION VII.

    NEW FORMATIONS COMPRESSING THE SPINAL  CORD.

  These occur under the same variety of forms which have
been already referred to in regard to the brain.  The most

             * Portal, Cours d'Anatomie Medicale, torn. iv.
                         39 
306       COMPRESSION  OF THE SPINAL  CORD.

common appear to be fleshy and albuminous  formations, tu-
bercles, hydatids, and ossifications.
   1.  A woman aged 36, had first  some convulsive motions,
which soon ceased ;  then  acute pain of the left arm with head-
ach :  the arm became weak, and gradually completely para-
lytic.  She then had convulsive motions of the lower  extre-
mities, which also became completely paralytic.   The right
arm next became painful,  and the motion of it was  impaired,
but not entirely lost.   The inferior  extremities became  cede-
matous ; the inferior half  of the thorax, and all the parts be-
low, were completely deprived of sense and motion : and the
right arm at last  also became entirely paralytic.   Extensive
gangrene then took place  on the sacrum, and she died gradu-
ally exhausted somewhat more than three  months  from the
commencement of the paralysis.
   Inspection.—On the anterior part of the cord, between the
body  of the cord and the  arachnoid, there  was a tumor of a
reddish-yellow colour; it was about three lines in thickness at
the thickest part, and covered the anterior surface  of the cord,
from  the sixth cervical nerves to  the third dorsal:  and the
part of the  cord which was covered by it was considerably flat-
tened.  Internally, the tumor was of a firm  fleshy consistence,
and of a yellowish-white colour.   On many  parts of the arach-
noid of the cord, cartilaginous scales were observed.*
   2. A young man aged 14, received a blow upon the spine, be-
tween the shoulders, by falling backwards against the corner
of a chair.   The only effects which immediately followed the
injury were, that he was observed to hold his  chin down to-
wards the breast, and that he complained, on raising his head,
of a pain striking through and across his chest.   After four
weeks, he was affected with weakness of his legs, which in-
creased till, in a short time, they became  entirely paralytic.
About the same time, he lost the power of retaining his urine
and faeces.   He had continued in this state for two or three
weeks, when his arms became paralytic, and he then lost the
power of moving his head.  He died on the following day,
about three months after receiving the  injury, having continu-
ed sensible to  the last.   During the progress of the  disease,
he frequently complained of great oppression and pain darting
through the chest.   On dissection, the viscera of  the  thorax
and abdomen were found to be healthy.  Some bloody serum
* Velpeau, Arch. General, de Med. January, 1326. 
COMPRESSION OF  THE SPINAL  CORD.        307
escaped in opening the head, but the brain in other respects
was  sound.   Much  bloody serum was discharged from  the
spinal canal, and, on opening it, a soft substance was  found,
four inches in length, lying between the bones and the spinal
cord at  the place of the injury.   When this substance was
taken out, and shaken in water, a great part of it was dissolved.
Parts of the same substance had  protruded through between
the transverse processes of the fourth and fifth dorsal vertebrae,
and  formed two tumors of similar soft matter, lying one  on
each side of the spine, in the hollow between the spinous and
transverse processes.  The largest of these was between three
and four inches long, one and a half broad, and about an inch
in thickness.  The spinal cord and the  vertebrae were sound.*
   3.  Tubercles are found of various sizes, either in the sub-
stance of the cord or attached to its membranes, and they pre-
sent the same  characters as the tubercles of the brain.    The
symptoms vary exceedingly, according to the seat and size of
the tubercles, or as they happen to affect particular nerves. A
child aged 12, mentioned by Ollivier, had been long  subject
to convulsive  attacks, which occurred  at irregular  intervals,
and  affected chiefly the arms :  he died  of phthysis.  A tuber-
cle, the size of a nut, was  found  betwixt the  dura mater and
the arachnoid of the cord at the third cervical vertebra.   In a
case by Bayle, there was tonic inflection of the fore-arm, hand,
and fingers;  and in  one by M. Gendrin, there were  epileptic
paroxysms, which always commenced  with a violent attack of
hiccup, of one or two minutes duration.  There were two large
tubercles in the substance  of the cord at its very origin.  In
a case  of paraplegia, mentioned in Majendie's journal, two
small tumors were found attached torfhe cord at its lower ex-
tremity.  Harderus found a tumor the  size of a nutmeg, com-
pressing the spinal cord of a young woman:  and there were
three similar tumors in the cerebellum.   From his description,
they were evidently tubercles, and the case was  complicated
with disease of the lungs and the liver.   The leading symp-
toms were, severe headach, oppressed breathing, and, a  few
 days before death, violent convulsions.
   To the various examples now given, of tumors and tuber-
cles of the cord, I shall only add  a case by M. Gendrin, which
 presents some interesting characters.   A woman aged 23, af-
 ter recovering from epidemic cholera,  felt great weakness, es-
* London Medical Obs. and Inq. vol. iii. 
308        COMPRESSION OF THE  SPINAL CORD.

pecially of the lower extremities, with anorexia, thirst, and oc-
casional diarrhoea.  After two months, the motion of both legs
was  found greatly impaired, especially of the left, in which
there was also diminished sensation, and a pain which extend-
ed from the origin of the sciatic nerve  quite to the  extremity
of the toes ;  and both limbs were affected with a sense of cold-
ness and prickling.   Soon after this she began to have pain
in the lumbar region, and this  was succeeded by acute pain
in both  limbs, with convulsive retraction of the toes.   This
pain was  most acute in the left limb, and there was now in-
creased sensibility of  the left foot, so that the slightest touch
produced a  sense of laceration; and this morbid sensibility
afterwards extended to the knee.   She had then fever, with
pectoral symptoms, and died gradually exhausted in October,
1832, which appears to have  been between six  and seven
months from the commencement of the disease.   The  right
limb was continually numb, but some degree of motion remain-
ed in both.   On inspection, there was found, at the lower ex-
tremity of the spinal cord, a firm white  tumor, the  size of a
filbert, enclosed in a cyst, and slightly softened in the centre.
It lay between the two  columns of the cord of the left side,
and, in some degree, encroached upon those of the right;  the
left anterior column,, in particular, was much distended  and
flattended by it.
  4. Hydatids in the spinal  canal have been mentioned by va-
rious writers.   A woman, mentioned by Esquirol, became epi-
leptic after a fright, and the  fits returned every second or third
day  with  great violence for three years.  She then became
comatose after one of the paroxysms, and died  in five days.
The pituitary gland contained  a cyst full of  a reddish-brown
fluid, and hydatids of  various  sizes were found within  the
sheath of the spinal cord through its whole extent.   In a case
of paraplegia of nine months standing, M. Chaussier found a
mass of hydatids  attached to the spine behind the left kidney,
and  a branch from the mass entered betwixt the vertebrae into
the spinal canal.  A  similar case  is related  by M. Reydellet
in the Diet, des Sc.  Med., in  which the tumor wTas opened,
and  the spinal cord was felt by the finger exposed at the  bot-
tom of it, after a large quantity of hydatids had been discharg-
ed.   The patient remained  paraplegic, and  afterwards  died,
gradually exhausted by the discharge from this cavity.
   5. Ossification of the membranes of  the cord has been  ob-
served in several cases.  In a woman who had been epileptic 
           DESTRUCTION OF THE SPINAL  CORD.        309

for five .years, and died  suddenly in one of the fits, Esquirol
found the sheath of the  spinal  cord, on its external surface,
covered through  its whole extent with osseous scales, from
one to two lines in diameter.  In a case, described by M. Bar-
bier,* the affection began with  prickling and numbness of the
legs, which extended very gradually, and was afterwards ac-
companied by acute pain in the limbs, and after several months
terminated in complete paraplegia, with incontinence of urine.
The patient, a woman  of  55, continued  in this state about
three years.   She was then seized with acute pain in the back,
extending into the stomach and abdomen, and down the legs,
and accompanied by vomiting, fever, delirium, and convulsive
motions of the limbs.  She died after a short illness, the dura-
tion of which is not distinctly stated, but seems to have  been
eight  or ten days.   At the third dorsal vertebra, there was an
ossification of the membranes of the cord half a line in thick-
ness,  three lines broad, and two inches long.  The inner sur-
face of this production was concave and  covered with a soft
membrane ;  and the portion of the cord included in it was al-
most destroyed, the membrane containing only a small quan-
tity of viscid fluid.  Above this,  the cord was firm and  heal-
thy ; below, it was much wasted.
  6.  The cord may also be compressed by a diminution of the
spinal canal, but this appears to be a very rare  occurrence. It
was, however, observed by Portal.  The canal of the last dor-
sal and two upper lumbar vertebrae was diminished  one half,
and its  inner surface was rendered unequal by numerous small
bony  eminences.   The inferior extremities were much wasted.
                     SECTION VIII.

    DESTRUCTION OF  A PORTION OF THE  SPINAL CORD.

  A man, whose case is related by Mr. Copeland, had  para-
plegia, dysuria, obstinacy of  the bowels, and a feeling of tight-
ness across his belly, as if a broad band had been bound tight-
ly round it.   His health had been declining  for more than a
* Traite Element, de Mat. de Med. 
 310        CONCUSSION  OF THE SPINAL CORD.

 year, and the commencement  of  his complaints was ascribed
 to having violently sprained his back in lifting a heavy weight.
 After being confined to bed with  perfect  paraplegia for three
 months, he died of gangrene of the nates.  On dissection no
 disease could be discovered in the vertebrae.   Within the last
 dorsal and first lumbar vertebrae, the spinal cord was entirely
 wanting for more than  two inches.  The membranes, which
 there formed an empty bag, were  unusually vascular and much
 thickened.*  On the other hand,  Ollivier found four inches of
 the cord entirely wanting  in  a child, aged 8 years, who  died
 of extreme marasmus, with caries of the vertebrae, but without
 loss either of sensibility or motion of the limbs.  Velpeau has
 described several cases, in which, in connexion with caries of
 the vertebrae, the cord was completely destroyed for the space
 of several inches, the patient having died of gradual marasmus
 without any appearance of paralysis ; and in Majendie's jour-
 nal, a case is described, in which the cord had become quite
 liquid, through two-thirds of the dorsal region and  one-third
 of the cervical.   The arms were paralytic without loss of sen-
 sibility, but the legs were  not affected.   Ollivier has also ob-
 served in two cases a remarkable wasting or diminution of the
 size of the cord.   The one was  in an old man, without any
particular  symptoms;  the other in an  idiot, with permanent
 contraction and wasting of the limbs.
                      SECTION IX.

            CONCUSSION OF THE  SPINAL  CORD.

  A severe blow upon the spine frequently occasions an im-
mediate loss of power of the parts below the seat of the injury,
without producing either fracture or  dislocation of the verte-
brae.  The extent of the parts affected will of course  depend
upon the seat of the injury.  Paraplegia and retention of urine
are  the symptoms which most commonly come under our ob-
servation ;  but if the injury be on the upper part of the spine,
there may also be paralysis of the upper extremities, difficulty
* Copeland on Diseases of the Snine. 
CONCUSSION OF THE SPINAL  CORD.
311
of breathing, and affections of the voice.   In tracing the far-
ther history  of this affection, the  following circumstances  are
worthy of attention,
  1. Concussion of the cord may be  speedily fatal without
producing any morbid appearance that can be detected on dis-
section.  Many  cases of this kind are on record.  Boyer men-
tions a man  who received an  injury of the spine by falling into
a ditch.  He was  immediately affected with complete para-
plegia, and died in consequence  of the injury;  the period  of
his  death is  not mentioned.   On dissection no disease could
be discovered either in the head or the spinal canal. Frank men-
tions four fatal cases of concussion of the  spine, in none  of
which could any morbid appearance be detected, either in the
vertebrae or in the spinal cord.
  2. It may be  fatal by inflammatory action taking place in
the  cord or its membranes, and terminating by ramollissement,
suppuration, or effusion.  Case CXLVI. affords an example
of this affection fatal by ramollissement.  A remarkable case
fatal by extensive suppuration, has been  already quoted from
Sir  Charles Bell.  Boyer  mentions a  man who fell  from  a
height of fourteen feet, and remained for some time senseless.
On  recovering from that condition he was found to  have lost
the  use  of his  lower extremities.  He had  also retention of
urine and involuntary discharge of faeces, and died  in twelve
days.   On dissection,  a quantity of bloody serum was found
in the spinal canal, the quantity of which was sufficient to fill
a little more than the lower half of it.
  3. Urgent symptoms  may follow the  injury,  and after some
time may be removed.   Galen mentions a man who, after an
injury of the back, was affected with loss  of  speech, loss of
voice,  and paralysis of the lower extremities, the  superior
extremities remaining unaffected.  After seven days he reco-
vered  his voice  and  speech,  and soon after the palsy also
disappeared.
  In summer  1816, I  saw a  man who had been employed in
blowing a rock near Edinburgh.   Not having retired to a suf-
ficient distance,  and  standing with his back to  the rock when
the  explosion took place, a large piece  of stone struck him on
the  spine about  the lower dorsal and upper  lumbar vertebrae.
He  instantly fell, completely  deprived  of power in  the lower
extremities.   I  found him in this state a few hours after the
accident, when he also  complained of violent pain, beginning
in the seat of the injury, and  extending downwards  along the 
312         CONCUSSION OF THE SPINAL  CORD.
thighs.   On the back there was an extensive swelling, which
made it impossible to ascertain the state of the vertebrae.   He
was confined to bed for several weeks without any power of
his lower extremities, and with considerable difficulty in passing
his urine, but gradually recovered, and in a few weeks more
was free from complaint.   The practice which was employed,
consisted chiefly of general and topical bloodletting.
   In Hufeland's Journal, vol. xxi., is related the case of a man
who fell from the top of a cart-load of  wood, and  lighted so
that the weight  of his body, on first coming to  the ground,
rested upon the back of his neck and shoulders, his head
being bent forwards.  When he recovered from the first effects
of  the shock, it was  found that he had lost completely both
feeling and motion of all  the parts below the neck; he could
move no part but his head, and he had retention of urine and
obstruction of the bowels.   After  eight or ten days, he was
affected with anasarca of the limbs, and a sense of prickling
followed by severe pain, but without any power of motion.
After lying several weeks  in this state onPerfect paralysis, he
began  to recover a slight degree  of feeling and motion,  be-
ginning in  the  fingers; and from this time, the  power  of
motion increased very gradually, so that at the end  of sixteen
weeks he was able to support himself in a sitting posture on
a chair.   After another long interval,  he was able to drag
himself about, supported upon crutches :  and, at the time when
the case was written, he was able  to walk a little  supported
by a stick,  and  to do a little work with his hands, but he con-
tinued to have  great weakness and pain of his back,  the
pain being chiefly referred to the junction of  the  spine with
the sacrum.   The progress of the functions of the  bladder and
the bowels, in this case, is somewhat remarkable.   He  had
first complete retention of urine, requiring the use of  the ca-
theter for four weeks ;  he then recovered the  power of passing
his  urine, but could not  retain it;  it flowed involuntarily, and
after sometime  longer, he recovered the power of retention.
The bowels were not moved without strong glysters  for six
weeks ;  after this the stools passed involuntarily for four weeks,
and he then recovered the natural action.
  A man, mentioned  in the  Journal Uwversel, torn, xxviii.,
fell from a tree and lighted on his back, and likewise struck
the back of  his head, in which a wound in  the integuments
took place.   He was for some minutes thrown into a state of
syncope; on  his recovery from which it was found that  the 
CONCUSSION OF THE SPINAL  CORD.        313
 lower extremities were entirely deprived of sense and motion.
 He had afterwards  retention  of  urine, tumefaction of the ab-
 domen, headach,  dilatation  of  the pupil, dxtreme anxiety,
 difficult deglutition, and stertorous breathing, and the pulse
 was as slow as 38 in a minute.  He recovered gradually, and
 was well in three weeks.
   Some cases of injuries of the spine have been accompanied
 by loss of motion without loss of feeling, and others by loss of
 feeling without loss of motion..  In a singular case described
 by Ollivier, there was incontinence of urine, with loss of feel-
 ing of the  penis and scrotum, and of the anterior, posterior,
 and interior part of the thighs,  without  any  loss  of motion.
 In such cases the sensibility of  the parts sometimes returns
 gradually, and in others the affection is permanent.
   4.  It  may produce  permanent paralysis.   This may occur
 immediately, or the first effects of the injury may be recovered
 from, and a new diseased action may take place after a con-
 siderable time.   Several examples of this have already occur-
 red under the foreAing heads.   The slight nature of the first
 symptoms,  in such cases, and the slowness of their progress,
 will be illustrated by the following case.

   Case CLI.—A  man aged 54, about twenty-five years agp,
 fell from the branch  of a  tree, and lighted on the sacrum.
 He was carried home, complaining  of  pain in the lower part
 of the spine, and  entirely paralytic in his lower extremities.
 In this state he was confined to bed about twelve days, and
 then recovered, so as to be able  to  follow his usual employ-
 ment ; but  from this time he was affected with a peculiar feel-
 ing of numbness, which was confined to the upper part of the
left foot.   This feeling gave him no inconvenience, but never
left him.  After he had continued in this state for four years,
 the numbness suddenly extended upwards along the leg and
thigh, and was  speedily followed by paralysis of these parts.
After  some time he was seized with pain, which stretched
across the  lower part of the  back, and  into the right thigh,
and was soon followed by paralysis of  the right thigh and
leg.   He was then confined  to  bed with perfect paraplegia
for about   two  ye^fs.   Some time 'after this he recovered
so much power as to drag himself about  supported upon two
crutches.   He was in  this  state  without  any farther im-
provement, when I saw him  for the first time, upwards  of
fifteen yearns ago.   His spine was free from distortion, but he 
 314         CONCUSSION OF  THE  SPINAL CORD.

 complained  of deep-seated pain upon pressure about the last
 dorsal vertebra, and at the top of the sacrum.  Two  caustic
 issues were inserted, and under the  action of them he made
 some improvement;  he was able to raise his legs a little higher
 in walking,  and occasionally to stand without  his  crutches,
 but from that time he continued stationary, and was much dis-
 tressed with incontinence of urine.
   The morbid action which takes place in such a case as this,
 will be illustrated by the facts which have been already re-
 corded.   It is probably of the nature of chronic inflammation
 of the cord or its membranes, terminating by some of the mor-
 bid conditions which have already been referred to.   We have
 seen  that such affections may supervene  upon very slight in-
 juries of the  spine, which do not at the time of receiving them
 induce any urgent symptoms,  and perhaps attract little or no
 attention.  Sometimes they take place after so, long an inter-
 val that the patient has forgotten the  injury, or, if he remem-
 bers it, does  not consider it as having any connexion with his
 disease.   A  man, mentioned by Sir Charles Bell, became pa-
 ralytic in the lower  extremities, several months after a slight
 injury of the spine, occasioned  by striking his  back against
 the corner of a table.   A gentleman walking in the fields near
 Edinburgh sprained  his  back slightly in leaping over a wall.
 He felt little uneasiness  at the time, but,  after several weeks,
 his lower extremities became paralytic.   In this state he con-
 tinued four or five months, and-then gradually recovered under
 the usual treatment.   In other cases the symptoms take place
 at an early period, and with such activity as distinctly marks
 inflammatory action.   A young man, mentioned by Dr. Jebb,
 received  a blow on the spine from a stone.  In the evening of
 the same day he was seized with shivering, followed by fever,
 which ran high through the night, but abated in the morning.
 He had at the same  time pain in the stomach  and back,  with
 contraction of the legs ; and this was  followed by weakness of
 the legs, which, after ten  days, increased to perfect paraplegia.
 Issues were then inserted, and he was able to walk in three
 months.
   Every injury of the spine should be  considered as deserving
 minute attention,  and  the most  active means should be em-
ployed for preventing or removing the  diseased actions which
may result from it.   The  more immediate  object of anxiety in
such cases is  inflammatory action, which may be of an active
or of  a chronic kind; and we  have seen that it may advance 
CONCUSSION OF  THE  SPINAL CORD.         315
 in a very insidious manner, even  after injuries which were of
 so slight a kind that they attracted at the time little  or no at-
 tention.   When the injury is of  a more violent  nature, there
 is indeed  another object of attention, that is, fracture or dislo-
 cation of  the vertebrae.   But we  have seen that the most ur-
 gent  symptoms may take place immediately after the injury,
 and may even  be  speedily fatal without any affection of  the
 vertebrae; while, on the  other hand, it is often impossible to
 ascertain the state of the vertebrae, in consequence of the  ex-
 ternal swelling which takes place.  It is likwise to be kept in
 mind, that fracture of the vertebrae  may happen without any
 displacement of parts, and in  such a situation, that it is im-
 possible to discover it.   A case is mentioned by Camper, in
 which paraplegia took place after an injury of the  spine, and
 which gradually recovered after twelve months.   On the death
 of the patient, which happened some time after from  fever, he
 found that one of the lumbar vertebrae  had been fractured in
 the body without displacement, and had united.
                   .*►
    Under this head, I may allude  very briefly to the subject of
 wounds in the spinal cord, in regard to which there  are some
 very singular facts upon record.   A young man, mentioned by
 Ollivier, was struck with a poniard through the  upper part of
 the neck, and fell instantly, deprived of feeling and motion of
 all the parts below the head.   He had also retention of urine,
 but recovered gradually, and was  able to walk a little in about
 five months.   In a similar case by Boyer, the man recovered,
 but with palsy of the right arm, and loss of feeling of the  left
 side in, all the parts below the thorax.   The case is well known
- of a man,  mentioned by Dessault,  who lived twenty-four hours,
 and moved all his limbs freely after  the cord had been com-
 pletely divided by a musket bullet at the tenth dorsal vertebra.
 A still more remarkable case is related in the Memoirs of  the
 Academy of  Sciences.  A  man  received a wound with a
 sword among the lower dorsal vertebrae, which  soon healed,
 and he was afterwards able for long  marches.   After a con-
 siderable time, the place became  painful, suppurated and was
 opened; and a piece of the  point of the  sword, two inches
 long, was extracted.  He died in thirty-six hours ; and it was
 found that  the sword had  penetrated between the spinous
 and oblique processes on the left side, that it had completely
 traversed the spinal  canal, and  had lodged in  the  opposite
 side.  A  man, mentioned in the first volume of the Archieves 
316    AFFECTIONS  OF THE BONES OF THE  SPINE.

Generates de Medecine, received a wound by a musket bullet,
which entered at the groin, and came out near the first lumbar
vertebra.  The wound soon healed, but after a short time loss
of feeling began around the cicatrix, and gradually extended
until it affected the  whole left side of the body except the
face.  Any part of the thorax, the abdomen, or the leg or arm
of that side, could he pinched with any degree of force with-
out feeling.   The  power of motion was preserved, though it
seemed weaker than in the other side.  His health was other-
wise unimpaired.  After the  affection had  continued in this
state for years, it was removed under the use of a succession
of large blisters.
                      SECTION X.

 OF  CERTAIN  AFFECTIONS OF  THE  BONES  OF THE SPINE.

  It would be foreign to my purpose to enter minutely upon
this important subject; but there are some circumstances re-
lating to it, which it may be proper to mention very briefly, in
connexion with the object of this essay.
  In the ordinary cases of carious and  distorted vertebrae,
accompanied by paraplegia, it is  well known that the para-
lysis is not produced simply by the distortion; for the distor-
tion may exist in a very great degree without paralysis; and,
when they have existed together, the paralysis may be entire-
ly removed, while the distortion remains undiminished. It ap-
pears that it is the inflammatory action of the parts which de-
ranges the function of the cord; that the effects of this in re-
ference  to the cord may subside, though  the disease of the
bones may go on to anchylosis  and permanent distortion; or
that, on  the contrary, it may terminate  by fungoid disease of
the membranes, or chronic disease of the cord itself, and thus
the palsy become irremediable.  The original disease appears ,
to be in  some cases seated in the  ligaments and membranes;
in others, in the articulating surfaces and intervertebral carti-
lages ; and  in others, in  the bodies of the vertebrae.  It  is
when the bodies of the vertebrae are  extensively affected,  that
the caries which follows produces distortion ; but even in this 
       AFFECTIONS  OF THE BONES OF THE SPINE.    317

case, distortion is not an invariable consequence, for the caries
may take place in such a manner as to diminish the size of
the vertebrae equally  along its whole surface, and thus merely
to shorten the spine, without  distorting it.   This is said to
occur most frequently in the lumbar vertebrae.   The case of
a boy related by Dr.  Armstrong, is  very important.  He had
involuntary discharge of urine and faeces, difficult  breathing,
and paralysis of all the extremities except a very imperfect de-
gree of motion in the left arm.   There was much pain and
tenderness on pressure in the cervical vertebrae,  but no distor-
tion. He recovered completely in a few months, the vertebrae
that had been affected remaining in a state of anchylosis.   In
this case, the disease was probably confined to the articulating
surfaces.   Mr.  Copeland gives a plate, in which three of the
dorsal  vertebrae are  represented as  united by anchylosis, the
intervertebral cartilages being removed, but without any loss
of substance in the bodies of the vertebrae.   In  this case, pa-
ralysis had taken place, but there was no perceptible distortion.
In attending to such  cases in practice, therefore, it is not suf-
ficient to ascertain the existence or non-existence of distor-
tion.   The whole spine should  be examined with care, with
the view of detecting the existence  of inflammatory action.—
This will be indicated  by pain or tenderness on pressure, or
pain on passing a hot sponge over the part in the manner re-
commended by Mr. Copeland.  The disease in its early stages
is sometimes of very small extent;  in a case which  occurred
to me  some time ago, it was limited to a spot on one side of
the spine, which could almost be covered by the point of the
finger; but it was of so peculiar a nature, that very moderate
pressure upon the spot produced syncope.   The patient was
an officer in the navy, and got well under the usual treatment.
   A minute  examination of the spine, therefore, should al-
ways be made with the utmost care, when any of those symp-
toms occur which have been  observed to be connected with
affections of the spine or spinal cord, especially if they do not
yield readily  to common modes of  treatment, or if they have
occurred after injuries of the spine.  The principal symptoms
of this kind are the following :—Weakness,  numbness, or
convulsive affections of any  of the limbs ;  spasmodic  starting
of the limbs, occurring chiefly during the night;  loss of  the
full power of the muscles, so that though the patient can walk
with sufficient steadiness, he cannot perform such  motions as
are required in running or leaping ; numbness along the mar- 
 318    AFFECTIONS OF  THE  BONES OF THE  SPINE.

 gin of the ribs, and a peculiar  oppression and tightness across
 the region of the stomach ; various affections of the  breath-
 ing ;  difficulty in discharging the urine and faeces, or difficul-
 ty in retaining them.   Complaints such as these have some-
 times been found to be connected with affections of the spine
 or spinal cord, after they had  been mistaken for dyspeptic or
 asthmatic disorders, or for diseases of  the urethra or rectum.
 A case has been formerly described, in which  an affection of
 the spinal cord,  at one period  of its progress,  was  accompa-
 nied by all the  symptoms of hypertrophia of  the left side of
 the heart; but these disappeared long before  death, and the
 heart was found on inspection perfectly healthy.
    It is indeed true, that diseases of a most formidable nature
 may exist in the cord itself or  its membranes, though nothing
 can be detected  by the most careful examination of the spine ;
 but these are quite distinct from the particular class of affec-
 tions which are  here referred to, and in regard to which we
 cannot be too  attentive in  watching the very earliest  indica-
 tions.   One symptom, in particular, which should always be
 contemplated with much suspicion, is a feeling of tightness or,
 constriction along the margin  of the ribs, as if a tight band
 were passed across the stomach.  This is generally  accompa-
 nied with a feeling of distention in the lower part of  the ab-
 domen, as if the bowels had in part lost the power of propel-
 ling their contents.   These feelings may be  considered  as
 merely flatulent or dyspeptic, and in many cases, they may in
 fact be nothing more ;  but they will likewise be found by an
 attentive observer, to be frequently  among the first indications
 of a dangerous affection of the spine, and to exist before there
 is any affection of the limbs, or any disease can be discovered
 in the spine itself.  In one of  the last cases that occurred to
 me, symptoms of this kind had existed for nearly three months
 before a projection was discovered in one of the lower dorsal
 vertebrae, and  this was soon followed by perfect paraplegia.
    It is worthy of attention, that symptoms affecting internal
 organs may exist in connexion with diseases  of the spine,
 without being attended by any affection of the limbs, or any
 symptom calculated to  direct our attention to the spine as the
 seat of the disease. A  girl, mentioned  by Mr.  Copeland, had
 difficulty and pain in emptying the bladder, pain and tightness
 round the margin of the  thorax, and difficult breathing;  her
» limbs were not affected, except that she was more  easily fa-
 tigued than her companions.   One of the dorsal vertebrae was 
        AFFECTIONS OF THE BONES OF  THE  SPINE.    319

found to project a little, and by topical bleeding and blistering
on this part, and rest in the horizontal posture, all her com-
plaints were removed.   A man, mentioned by Dr. Jebb, had
pain under the  short ribs  on both sides, cough, and  irregu-
lar pulse.   From the parts affected lancinating pains extended
downwards along the thighs, occasioning much uneasiness in
walking, resembling the pains of  rheumatism.  The  ninth or
tenth dorsal vertebra was found to protrude, and by issues ap-
plied at that place, all his complaints were removed.
  The remedies on which we chiefly rely in all cases of this
kind are topical bleeding, blistering, issues,  and rest in the
horizontal posture ; but some cases are on record, shewing in
certain conditions of the disease the beneficial  effects of mer-
cury.  A girl, mentioned by Sir  Charles Bell, after an injury
of the spine, was confined to bed  for eight months in the most
helpless state, her back bent, and her knees drawn up. She reco-
vered entirely under a course of mercury, given her on account
of syphilis, with which it was discovered that she had been
affected from the time of the accident.   In the transactions of
a Society for the Improvement of Medical and Surgical Know-
ledge, is related the case of  a man, who had squinting, diffi-
culty of swallowing, indistinct articulation, paralysis of the
left leg and arm, and protrusion of several of the cervical ver-
tebrae.   Under  a course of  mercury all his complaints disap-
peared,  and the protrusion  of the  vertebrae was diminished,
though not entirely removed.  Several  cases have recovered
by confinement  to the horizontal posture without any other
remedy ; this occurred in Dr. Armstrong's case, lately refer-
red to.

  The spine may be affected with extensive caries without the
existence of any symptom that marks such a state of disease.
A man, mentioned  by Sir Charles  Bell, who had been liable to
severe pain in his back, and  fits of palpitation, died suddenly
after a long walk.   The only morbid appearance observed on
inspection was  a large scrofulous  abscess in the posterior me-
diastinum, with caries of several of the vertebrae, of such ex-
tent that the spinal cord was exposed in several places. I saw
a similar abscess in the posterior  mediastinum, with  caries of
the bodies of five or six of the vertebrae, in a girl who died of
phthisis.  She  had complained for some  time of severe pain
in the back, but her complaints in other respects did not differ
from the usual  symptoms of phthisis.  A similar appearance 
320    AFFECTIONS OF  THE BONES OF THE  SPINE.

in the lumbar vertebrae, with a psoas abscess containing two
pounds of matter, has been described by Mr. Benjamin Bell.*
The vertebrae were  so  diseased, that  large pieces of them
were separated, and the  matter was in several places in con-
tact with the spinal cord.  The patient, a man of 40, had
complained of severe pain in his back and thighs, which pre-
vented him from raising  his body into  the erect posture, but
there was no distortion  of the  spine, and no paralysis.   He
had considerable difficulty of breathing, but this was account-
ed for  by a diseased state of the  lungs.   Other remarkable
cases are on record,  showing extensive disease of the spine
without any fatal result.   Duverney found the atlas so brought
forward-upon the foramen magnum, that there was not a space
of more than two lines in diameter left for the cord ;  and Ber-
tin has described a preparation in which the atlas was so an-
chylosed with the occipital bone, that its posterior arch cross-
ed the centre of the foramen magnum.  The history of this
case is not given, but it is evident from the anchylosis, that it
was not speedily fatal.   Similar contractions  have occurred,
though not to the same extent, in the ordinary cases of caries
of the spine, terminating by distortion and anchylosis,  but
without paralysis.

   In connexion  with this subject, it  may be  right to allude
very briefly to some of the phenomena connected with the  af-
fections of the processus dentatus.
   1. It may be  affected  with  caries without  producing any
urgent symptoms,  until it suddenly give way and prove fatal.
A man, mentioned by Mr. Copeland, had been using mercury
for a disease in the tibia, and had for sometime complained of
stiffness and  pain  when he moved his  head.  On  making a
sudden turn of his head he was seized with convulsions, and
died in a few hours.   On inspection, the processus dentatus
was found completely detached from the vertebra, having been
eroded by caries.  A woman, mentioned by Ollivier, had pain
in the neck and difficult deglutition ; the muscles of the  neck
were rigid, and the least  motion  of the head was insupporta-
ble, so that she was constantly confined to the horizontal pos-
ture, and  almost to one  particular position ; she then had
cough and  difficult breathing, and at last  died after  several
months.  There  was extensive disease  of the lungs, and the
* Edin. Med. Com. vol. iii, 
AFFECTIONS OF  THE BONES OF  THE  SPINE.    321
processus  dentatus was entirely destroyed  by caries.  The
posture in which this  woman had  been long confined, pro-
bably prevented her more sudden death.
  2. It may be dislocated by violence, of which many exam-
ples are on record.  A man, mentioned by  Sir Charles Bell,
was making a violent  effort to propel a wheelbarrow from the
street upon the raised  foot pavement, when the barrow sud-
denly went from before him, and he fell  with his  chin upon
the curb-stone.  He was dead  in  a few seconds ; the pro-
cessus dentatus was found to have  crushed  the spinal cord,
the ligaments having given way.
  3. It appears that the ligaments  of the processus dentatus
may yield in a more gradual manner, giving rise to a course
of  urgent  symptoms  for  some time before the affection is
fatal.   Some  years ago, a man was received into  the  In-
firmary  of Edinburgh, who had been  accustomed to  carry
burdens on his left shoulder, his head consequently being bent
to the right side.   He complained  of pain in the forehead and
occiput, extending down the neck, pain in  the throat, great
difficulty, or rather impossibility of swallowing, articles taken
into the oesophagus being rejected  with some violence after
they had passed a short way.   He had  rigid contractions of
the neck and back, resembling tetanus ; his articulation was
slow and difficult, and the pulse 54.  These complaints  had
begun about six weeks before,  and had  been increasing gra-
dually ;  difficulty of swallowing was one  of the  first symp-
toms.   Two days after his admission, his  left side became
paralytic;  on the following day, the right was affected in the
same manner, and his breathing became laborious.   He died
in  three days  more, having lost all power of moving the parts
below the neck.   On inspection, it was found that the  liga-
 ments had given way on  the left side of the processus denta-
 tus, so as to allow it  to compress the spinal cord.  No other
 disease could be discovered in any of the viscera.

    For the following important case I am indebted to Dr.
 Hunter.   It illustrates in a striking manner many of the ob-
 servations made in this section, and shows, in connexion with
 the disease of the  vertebrae, complete  paralysis, without any
 remarkable affection  of the body of the cord.

    Case CLII.—A young lady, aged 15, in the beginning of
 the year 1825, began to  complain of a dull pain in the neck, 
322    AFFECTIONS OF THE  BONES  OF THE SPINE.

which, to a certain extent, limited its motions.  She became
languid,  depressed, and sallow ;  and the symptoms went on
in this manner, without exciting much attention, till about the
middle of March.   Dr. Hunter was then consulted about her,
on account of an  increase of the uneasiness  in  her neck,
which was accompanied by considerable swelling in the back
part of it.  Several tumors had  also  appeared  on  the scalp,
in which fluctuation was felt, and on opening them, the bone
beneath was found to be carious.  The swelling of the neck
gradually increased  to a great  extent  on each side of the
spine, and became irregularly softened; and  when opened,
discharged ill-conditioned strumous matter, in  small  quanti-
ties.  The pain in the neck increased to such  an  agonizing
degree as totally to prevent motion ; it extended at times to
the left side of the head  and face,  and fixed, for a certain
time every day, with excruciating  severity, over the left eye.
At an early period of her illness,  numbness of the superior
extremities took place, which increased to perfect paralysis;
there was also rigid contraction of the flexor muscles  of the
legs, with a slight degree of twisting  of the  mouth.  The
pulse became frequent; the breathing was  natural when she
was awake, but during sleep was accompanied by a loud
snorting noise.  The  appetite  was tolerable, and  the  other
functions were natural.  The caries of the bones of the skull
gradually penetrated both tables, without any affection of the
sensorium occurring.   One  or two new openings took place
in the swelling on the neck, from which a discharge conti-
nued.   She became gradually more and more emaciated, and
died exhausted on  the 1st of  January, 1827.
   Inspection.—An incision being made on  the back  of the
neck, and carried down to the spine, gave vent to a consider-
able quantity of matter which lay in contact with  the verte-
brae ; and the surrounding soft parts were in a state of pulpy
degeneration.   The  four upper  vertebrae were found to  be
more or less affected with caries, which was mcfst remarkable
in the first and second.  The articulating surfaces of the atlas
were deeply eroded, and there  was a similar  erosion  of the
articulating surfaces of the  occipital bone.   In the  second
vertebra, the processus dentatus was  entirely separated from
the body of the bone, the caries  having completely penetrated
it at its attachment, and there was besides  considerable loss
of  substance  on  the  posterior  part  of the vertebrae.   The
membranes of the  cord were thickened, and the cord  itself 
        AFFECTIONS OF THE  BONES  OF THE  SPINE.     323

 was a little softened at the upper part, but in  no remarkable
 degree.
   A remarkable case, analogous to this, is mentioned by M.
 Meyrieu.*   The patient had pain  and stiffness of the neck,
 his head being bent to one side,  and  immoveable; difficulty
 of swallowirfg ; and after some months, palsy of all the limbs.
 He died suddenly when his head was  accidentally moved in
 doing some necessary office  about his bed.   The external
 parts of the neck presented a  mass of soft disease.  There
 was caries  of  the right condyle of the  occipital bone, of the
 right side of the atlas, and of the processus  dentatus;  and
 there was destruction of the ligaments, so that the atlas was
 luxated from the occipital bone.

  I conclude this part of the subject with  the following case,
 which shows  disease of the processus dentatus, complicated
 with  a  new formation,  presenting the  characters of  fungus
 haematodes.

  Case CLIII.—A gentleman aged 22, of a scrofulous habit,
 in the early part of his life had suffered amputation on  ac-
count of a  disease of the knee, and afterwards was  liable to
pectoral complaints with haemoptysis.    In the  beginning of
the year 1828, he began to complain of pain and stiffness of
the neck, referred chiefly to the left side of it, and much  in-
creased by  the motion of  the  head.   The pain sometimes
extended into the larynx, and backwards towards the scapula.
After considerable relief from  repeated blistering,  &c.,-the
symptoms returned, accompanied by loss of appetite, frequent
pulse, and night perspirations ;  and soon after this he became
affected with difficult deglutition,  some dyspnoea and hoarse-
ness.   There was  now also severe fixed pain referred to  the
back, of the head, and much increased by  the motion  of  the
parts ; so that he was obliged to support his head with both
his hands when he had occasion to make any change  of his
posture.  He was next affected with paralysis of the tongue
and the upper  eyelid  of the left side.  On 16th January, 1829,
he was seized  with paralysis of the left arm, and two days
after the right  was affected in the same manner.  He had then
great pain and difficulty in passing urine,  with obstinacy of
the bowels, which nothing could overcome.   On the  29th,
* Bull, de la Soc. de Med. 
324     AFFECTIONS OF THE BONES  OF THE  SPINE.

the lower extremities became paralytic, and he  died on  the
31st, having suffered greatly on the  day on which  he died,
from difficult breathing.
   Inspection.—All the external parts of the  neck,  the pha-
rynx, &c, were healthy, and no disease was discovered in any
of the vertebrae in their external aspect.  The brain and ce-
rebellum were healthy,  except some increase of vascularity.
Within the foramen magnum, and  attached to the inner surface
of the dura mater at its anterior and lateral parts, there was a
spongy tumor  of a greyish-yellow  colour, which, when cut
into, presented a variegated structure, resembling fungus hae-
matodes.  The processus dentatus was rough and carious on
its surface, and it was  so  much  elongated as to project half
an inch into the cavity of  the cranium.   Its ligaments  also
were partially destroyed, so as evidently to  allow  it to en-
croach upon the area of the spinal canal, and to compress the
cord.   The spinal cord at the upper part was flattened, but
not materially  altered in its texture.
  In  regard  to the treatment of the diseases  of the spinal
cord,  it is not necessary to enter  into  any long  detail, as it
must be regulated by the same principles as  the correspond-
ing affections of the brain.  In the more acute affections, we
must  of course rely chiefly on free general and topical bleed-
ing, assisted  by  blistering, purgatives, and  the other  usual
auxiliaries.   When the affection is in  a more chronic  form,
the treatment will consist chiefly  in local applications, as to-
pical  bleeding, blistering, and issuses, aided by the horizontal
posture.   In the early stages of  such affections, I think the
most  satisfactory treatment, after  free topical bleeding, is by a
succession of blisters,  applied first on  one  side  of the spine,
and then on the other, in quick succession, and repeated in this
manner to a  considerable number.  In some of the cases great
benefit is also obtained from continued moderate purging. 
PATHOLOGY  OF THE  SPINAL CORD.         325
                      SECTION XI.

 CONCLUDING  OBSERVATIONS ON  THE PATHOLOGY OF THE
                      SPINAL CORD.
                                                       *

  The preceding observations on the diseases of the spinal
cord, I merely propose as an imperfect plan or outline of this
most important subject, in the hope that  it may engage  the
attention of those who have opportunities for  prosecuting the
inquiry.  When we review the phenomena which have been
observed to accompany the diseases of the spinal  cord, we
find affections of all the principal organs of the body.  In the
parts connected with the head and neck, we  find distortions
of the  eyes, convulsive affections of the face, difficulty and
loss of speech, loss of voice,  contraction of the  jaw, resem-
bling trismus, and difficulty of swallowing, which is said, in
some cases, to have nearly resembled hydrophobia.  In  the
viscera of the thorax, there have  been observed oppression,
palpitation, and strong and  irregular  action of the  heart;
painful sense of stricture in the region of the diaphragm, and
difficulty of breathing, which, in some cases, has been per-
manent, and in others, has occurred in paroxysms, resembling
asthma.  In the organs of the abdomen and  pelvis, we find
vomiting, pain of the bowels, resembling cholic ; tenesmus,
involuntary discharge of faeces, and retention or  incontinence
of urine.  In the muscular parts we observe convulsions and
paralysis; the convulsions in some  cases resembling chorea,
in others tetanus.   We are by no means  prepared to say, in
the present state of our knowledge, that all these proceed di-
rectly from the affections of the spinal cord, especially as we
observe remarkable diversities and considerable want of uni-
formity in the symptoms.   But the  subject presents to us a
field of observation which promises most important  and most
interesting results.  It has also opened up a wide  field of con-
jecture, in regard to the influence of the spinal cord, in several
diseases which have hitherto  been involved in much obscurity.
These conjectures are not to be altogether overlooked, but are
of value only  in as far as  they direct us to subjects worthy of 
326         PATHOLOGY  OF THE SPINAL  CORD.
being investigated by farther observation.   They have chiefly
referred to the following points.

   Spasmodic Diseases.—Several writers  of eminence  have
conceived that many spasmodic  and  nervous diseases  have
their origin in affections of the spinal cord.   Hoffman, in his
Essay de Morbis Discernendis, directs us to distinguish be-
twixt epilepsy and convulsions.   In the former, he  says the
membranes of the brain are affected, in the latter,'the mem-
branes of the spinal cord.   In his Treatise de Morbus  Con-
yulsivis,  he divides convulsive affections into idiopathic and
symptomatic.   The  former he thinks arise from irritation  of
the membranes of the spinal cord ;  the latter he supposes  to
depend upon diseases of other organs, and that the  effect  of
them, by the influence of these diseases upon the spinal  cord,
is extended over the whole body.  Ludwig discusses the  same
doctrine  more  particularly, ascribing many hypochondriacal
and hysterical affections to  irritation at the origin of the inter-
costal nerves, and explaining the  affections of the lungs, the la-
rynx, &c, in such diseases, by the connexion of these nerves
with the par vagum.  Lieutaud  contends that  all  convulsive
affections, in which the speech is  not impaired, depend on
diseases  of the spinal  cord, and  he considers tetanus  as an
example.  The same doctrine is supported by Burserius, Fer-
nelius, and Belfingerus (De Tetanto.)  Portal supposes  that
slight pressure on the spinal cord  produces convulsion, and
greater, paralysis ; and he thus accounts for the  one passing
into the other by gradual increase of the pressure.
  In the present state of our knowledge it must be confessed
that these doctrines, however ingenious, are to be considered
as little better than conjecture.  Many facts, however,  have
been already  related, and others are on record, which show,
in connexion with diseases of  the spinal cord,  symptoms
closely resembling  those of chorea and  tetanus.   Hoffman
mentions a boy, who, after  a blow on the sacrum, was seized
with a violent convulsive affection nearly resembling  tetanus,
with loss of memory, difficult articulation, and delirium.  The
complaint continued with great severity for five days, and af-
terwards returned at nearly  regular periods for  six  months.
Burserius relates the case of a man who died of tetanus, in-
duced by exposure to cold after intoxication ; on dissection  a
large quantity of viscid yellow serum was found  under the
outer covering of the spinal cord.  Frank also relates a case 
CONCLUDING  OBSERVATIONS.
327
of '.' horrible tetanus," which was induced by a blow upon the
spine, but he gives no account of the appearance  on dissec-
tion.   Several cases  have been  detailed in which, in various
diseases of the spinal cord, symptoms occurred,  closely re-
sembling tetanus.  And this important subject has been farther
investigated by Dr. Reid in his work on tetanus.   Upon the
whole, however, the  truth appears  to be, that though symp-
toms strictly tetanic  do accompany various affections of the
spinal cord, the disease properly to be considered  as idiopathic
tetanus  is entirely of a  different nature, and that the patho-
logy of it is still involved in great obscurity.
  2. Colica Pictonum.   I have referred to the case of a wo-
man, mentioned by Bonetus, in whom paralysis followed severe
colic, and  extensive serous effusion  was found  under the
membranes of the spinal cord.   Privatius, as  quoted by Sau-
vages,  mentions a woman, who after  suffering  from violent
gastrodynia for three hours, was attacked with palsy of all the
parts below the neck, and died in two  months.    At an early
period  of 'the disease, protrusion had taken place of the last
cervical vertebra, but no account is  given  of the  dissection.
In this case, the pain was supposed to be symptomatic of the
disease in the spinal cord;  and, similar to this is the view
which  several continental writers have taken of Colica Picto-
num.   They consider it as a real inflammation of the spinal
cord, (Rachialgia Saturnina,) and  on this  principle they  have
proposed to treat it by bloodletting.*  This opinion, however,
has not been  confirmed by farther and more accurate observa-
tion.   M.  Gendrin  examined  carefully four cases  of  long-
standing, and could  not detect  any  appearance  of  disease,
either in the brain, spinal cord, or their membranes.
  3. Fever.  Ballonius ascribes many of the symptoms  of
fever to an affection of the spinal cord, particularly the  pain
in the  back," tremors  of the limbs,  and oppression of  the
breathing.!   A remarkable  case has been quoted from Brera,
in which the  cord  became affected  in  a  case of  malignant
fever;  and Rachetti  relates the case of a  girl who  died  of
petechial  fever which had induced coma.   On  dissection,
there were found evident marks of inflammation in the spinal
cord and its membranes, and a  quantity of puriform  matter

  * Astruc Qusestio Medica, An morbo Colica: Pictonum, rectius Kachialgiae, veuoe-
sectio ?                                              a
  f Ballonii Consilia Modica. 
328         PATHOLOGY OF THE SPINAL CORD.
about the cauda equina ; there were also marks of inflamma-
tion in the brain and its membranes.*
  4. Epilepsy.  M. Esquirol, some years ago, presented to
the Faculty of Medicine at Paris, a memoir on  epilepsy, in
which  he states that he had examined the bodies of fifteen
patients whe died  of this disease,  and found the spinal  cord
affected in all of them.  The  dissections, however, presented
no uniformity of appearance.   In  one there were  hydatids;
in another the membranes were as if injected; in a third the
arachnoid of the cord  was of a greyish  colour.   In several
of the cases the medullary substance of the  cord was  softer
than natural at particular parts, and in one it was harder.   In
one case  the spinal cord at the eleventh  and twelfth dorsal
vertebrae  was soft  and  of a  light brown colour.   In a young
woman, in whom  the paroxysms returned with menstruation,
he effected a cure  by repeated  applications  of  moxa to the
spine.
   5.  Hydrophobia.  M. Salin seems  to  have been  the  first
who conjectured that,  in this  horrible disease, the spinal cord
is affected;  and a case is  related in  Dr. Johnson's  Medico-
 Chirurgical Journal for October, 1817, which seems to afford
 some probability to the conjecture.   The case was well marked,
 violent, and speedily fatal.  The  membranes of the  brain
 were found highly vascular, with considerable serous effusion;
 but the  principal marks  of disease were  in the  coverings
 of the pons Varolii, medulla oblongata, and the upper part of
 the spinal cord.   These parts are said to have  formed one
 crust  of  intense  inflammation,  and> on  the  spinal  cord, this
 crust  was more intense than in any of the other parts.  M. Gen-
 drine, however, states, that he has assisted at the examination
 of many cases of hydrophobia, and never could discover any
 disease either in the spinal cord or the nervous ganglia.
   6.  Many cases  of Dyspnoea are supposed  by Frank to pro-
 ceed from disease at the origin of the phrenic  nerves; and
 difficulty of speaking and of swallowing frequently  depends,
 according to Portal, on " engorgement " in  the  cervical por-
 tion of the spinal cord.

   I leave these conjectures for the investigation of the reader,
 and shall hasten to bring this essay to a close, by a brief allu-
 sion to some points which  seem to  be related to the subject,

   * Rachetti della Strulura, dclle funzoni e delle Malattie della Midolla-Spinali. 
CONCLUDING OBSERVATIONS.
329
while they show the difficulties  and obscurities which  at-
tend it.
  Several very remarkable cases have occurred to me which
presented all the characters of extensive disease of the spinal
cord, while nothing could be found, either in the brain or the
cord, that could in  any degree account for the symptoms.
Several of the same kind, in which the symptoms.were equally
decided,  are mentioned by Dr. Bright.

  Case  CLIV.—A woman aged 35, was first  affected with
numbness in the thumb of the left hand,  which gradually ex-
tended over the whole hand and arm.  The limb was then par-1
tially paralytic, and was likewise affected with involuntary mo-
tions exactly resembling those of chorea.   This continued  se-
veral weeks, and then gradually ceased, and the arm recovered
its healthy state.  Almost immediately after this, the right hand
and arm were affected in the same manner, and after some
time also got well.   The legs then became affected with start-
ing, involuntary twitches, and a feeling in walking, as if they
would start from under her to one side.   The complaint went
on in this  manner for  some time, and  then  terminated in
complete paraplegia, with  retention  of  urine, requiring the
constant  use of the catheter.   She was now confined to bed
for nine months, and died  of extensive gangrene of the  sa-
crum and tops of the thighs.  For some time before her death,
she had recovered the action of  the bladder.
  Inspection.—No disease could be discovered in the brain or
the spinal cord, except that the cauda equina  was of a very
dark colour, as if it had been soaked in  venous blood, and
there was some bloody fluid around it.  The sacrum was  re-
markably soft,  and in some places carious ;  and it was covered
externally by a deep and extensive sloughing sore.  All the
other viscera were healthy.

  Case  CLV.—A medical gentleman aged 30, who had been
for several years in the navy, returned home in perfect health,
and was  living in Edinburgh, when he was observed by  his
friends to drag his legs awkwardly in walking.  He was not
himself at first sensible of it, but soon perceived a weakness
and want of command  over both  his legs, which  gradually
increased to nearly perfect paraplegia.  Some  time  after  the
affection  of the legs took place, he began  to lose the power
of his  arms, and this also increased,  till he retained in them 
330         PATHOLOGY OF  THE  SPINAL CORD.

only a very feeble and unsteady power of motion.   They were
also  frequently seized with convulsive startings, so that  any
article which he attempted to hold was thrown from him with
violence.   The legs  often started in the same manner, and
were thrown about with considerable violence, especially when
he attempted to move them while  he was sitting up.   No dis-
ease could be discovered  in  the bones  of the spine, and he
was  otherwise in good health, until about two years after the
commencement of the complaint,  when  he  was seized with
phthisis, of which he died in September, 1822.   I examined
the body with the utmost care, and could not discover a  ves-
tige  of disease either in the brain  or the  spinal cord.

  Case CLVI.—A woman aged about 20, a servant, sprained
her back in lifting some heavy article of furniture.   She felt
at the time no great inconvenience, but some time after, weak-
ness of the legs  took place,  which gradually  increased to
perfect paraplegia.  After some time the affection extended
to the arms, and she then had not a vestige of motion of any
of the parts below the head,  except a very  slight motion of
some of the fingers ; but the internal functions were rall en-
tire,  and her  speech was distinct, except that, in  speaking,
she was sometimes  seized  with spasmodic  twitches of the
lips  and lower jaw.   She  lived in this state without any
change in the symptoms, her general health continuing good,
for about twenty years.  In the morning  she  was taken out
of bed,  and placed in a chair  so  contrived as to support her
in a  sitting  posture.  Her  arms were  supported  on a cross
board which  passed before her; and if, by any accident, one
of them slipped from this support, she had no resource but to
call  the assistance  of another person to replace it.   Having
been on one occasion left alone for about two hours, after one
of her arms had thus slipped down, the hand had become ex-
tensively cedematous.   In the same manner, if her head fell
forward upon the  thorax, it  remained in that  position until
raised by an  attendant.  Her mind was entire.  She died of
four  days' illness, with symptoms of low typhus fever.  I ex-
amined the body with the utmost  care, along with  Dr.  Pit-
cairn, who had been in the  habit of seeing her for several
years, and we could not discover  any disease, either in the
brain or the spinal cord.

  Case CLVIL—A lady aged 30, had  been liable for seve- 
CONCLUDING OBSERVATIONS.
331
ral years to a feeling of stiffness of her neck, with an uneasy
feeling in the back part of it, which made her sometimes sit
with her head bent  very  much forward, and  at  other times
thrown backwards ; about two months  before her death these
feelings increased, and were accompanied by pain, extending
along both the arms ; at  first like rheumatic pains with stiff-
ness, but soon amounting to paralysis.  She had now only a
very imperfect motion below the elbow, and  could not raise
either arm to her head ;  there was very slight motion of the
fingers, and  they were sometimes spasmodically contracted.
The speech became thick and partially inarticulate;  she had
considerable difficulty in  swallowing, and she observed  that
there were certain positions of the neck, in which she could
swallow with greater facility than in others.   Her pulse  was
good, the other functions were natural, and the motion of the
lower extremities was not at all affected.   About a  fortnight
before her death, she became affected with  dyspnoea, which
occurred in paroxysms, sometimes very severe. An appear-
ance of projection was now observed, with pain upon pressure
in several of the lower cervical vertebrae.   Issues were insert-
ed in this place, and for  a week she seemed better;  she was
free from dyspnoea,  and the motion of the arms was consider-
ably improved.  On the evening of the 4th October, she be-
came suddenly comatose  with some convulsion, and had a pe-
culiar convulsive motion  of the lower jaw, which was for some
time in a state of constant and  rapid motion, opening and
shutting with violence.  The arms also became more paralytic.
She seemed  relieved  after a  bleeding, but, after two hours,
sunk again into a comatose state, and died suddenly.
   Inspection.—In the upper part of  the pharynx and larynx,
there was a superficial redness like very recent inflammation ;
but, on the most careful examination, no disease could be dis-
covered in the brain, the spinal cord, or the bones of the spine ;
and all the other viscera were in  a healthy state.

   I shall add no comment on the simple relation of  these re-
markable affections, but merely illustrate them by an important
case described  by Bretanneau.*   A lady, whose  age is not
mentioned, was  affected with palsy in the little finger of the
left hand, which gradually extended over the hand, and then
over the arm.   The left lower extremity then became affected
* Revue. Medicale, May 1826. 
332
PATHOLOGY  OF THE SPINAL CORD.
in the same gradual manner, and  after this, the arm and leg
of the right side, with  the exception of  the  thumb  and  two
fingers of the right hand, which preserved the power of motion.
The motion of the tongue was then lost,  and at last deglutition
was much impeded.   She preserved her intellect to the last,
and expressed herself by moveable letters, which she arranged
with the thumb  and two fingers of  the right hand, of which
she preserved the power.  The duration of the disease is not
mentioned.   There was a small quantity of  fluid in the ven-
tricles of the brain;  but the brain itself, the  cerebellum, and
spinal cord, being examined with the utmost care, were found
perfectly healthy, with the exception of a small spot upon the
tuber annulare.  On the right side of this, at the depth of four
lines, there was a portion three lines in  extent, of the  colour
of rust.   Its centre was of the deepest colour, and its circum-
ference  irregular,  gradually losing  itself  in  the surrounding
substance ; and it seemed rather harder  than the other parts.
  The mobid appearance, in this  singular case, has  a remark-
able resemblance to the morbid condition of a small part of the
brain, formerly referred to, and exemplified in Case  CXXXV.
It is probably the result of a slow inflammatory action, limited
to a very small portion of the cord, in the  same manner as we
have seen it in the brain.   There is reason to expect, that a
very minute examination of the whole  cord, in  such cases,
may discover  similar  changes  of structure,  calculated to
throw light upon affections which are at present  involved in
much obscurity.   The following is one of the most remarkable
that I find on record.
  A woman, mentioned by Ollivier, a servant, was suddenly
seized while  making a bed, with  a very  strong sense of prick-
ing in the points of the fingers of the left hand, and the points
of the toes of the left foot; and half an  hour after,  the same
parts on the right side were affected in the same manner.  She
continued to go about for three  hours, after which she was
obliged to sit down from a feeling of fatigue ; and after sitting
for  some hours, she was carried to bed.   Next day, there was
paralysis of all the limbs, but in the greatest degree on the
left side.  The sensibility of the parts was not impaired.  Re-
spiration was performed with a kind of effort, and  at night
became very  difficult.   On the third day,  respiration was ra-
ther improved, but there was difficult  deglutition.   In the
evening the  difficulty  of breathing  increased, with frequent
pulse and strong action of  the heart, and she died  at  night. 
CONCLUDING  OBSERVATIONS.
333
There was a slight appearance of infiltration of blood in  the
cellular tissue on the outside of the dura mater of the cord, es-
pecially about  the lower part.   No other vestige of disease
could be discovered either in the brain or the spinal cord; and
all the other viscera were in the most healthy state.

  I conclude this subject with a brief allusion to certain  ob-
scure and anomalous affections, which, like those now men-
tioned, present many of the characters of disease of the spinal
cord, though their  termination in general  is more  favourable.
The affections  assume  a great variety of  characters, and  the
nature of them is  exceedingly obscure.   The most  common
symptoms are  various spasmodic affections of the limbs, or of
the muscles of the back, sometimes resembling chorea, or even
tetanus; and  various degrees of weakness of the lower  ex-
tremities, sometimes amounting to complete paralysis, which
is often accompanied by remarkable spasmodic affections of
the  paralytic limbs.    There is generally a great feeling of
weakness in the back, and frequently pain, which is sometimes
confined to one part, but more commonly extends in a greater
or less degree  along the whole of  the spine.   Various affec-
tions of the breathing likewise occur, sometimes with  attacks
of palpitation,  and various uneasy feelings in the stomach and
bowels. The affections occur almost entirely in females, chiefly
those of the higher ranks, and are generally extremely tedious
and untractable.  It is indeed difficult to say what treatment
has any decided control over them ; but the # remedies which
appear to be most beneficial are, free and regular  purging, or
a combination of tonics and anti-spasmodics, with small doses
of purgatives ; strong friction ; cold spunging or shower bath,
and blistering  on the spine.  The affections  commonly pass
off, without leaving any bad  consequences,—sometimes very
suddenly, and without  any cause to which  their removal  can
be ascribed.
   One modification of these singular affections will be illustrat-
ed by the two following cases, which lately occurred to me
in the same family.  A strong  and healthy girl, aged 8, of a
full habit and  florid complexion, was observed to  stumble fre-
quently in walking, and  occasionally to fall; and this, with-
out any farther warning, was followed in a very few days, by
perfect palsy of both lower extremities.   I saw her about a
fortnight after the attack,  and found the limbs  completely pa-
ralytic, with frequent spasmodic contractions.   Nothing was 
334         PATHOLOGY  OF THE  SPINAL CORD.

to be discovered about the spine, and she was in other respects
in excellent health;  the bowels were rather confined, but easily
regulated.  About a month after the commencement of this af-
fection, her elder sister, aged 16, who had been rather  deli-
cate, and at times hysterical, was observed to walk awkward-
ly, and, in a few days, she  lost entirely the  use of the lower
extremities.  She was now for some  time in a great measure
confined to bed, and the affected limbs were liable  to strong
spasmodic contraction ; her knees being drawn up to the abdo-
men, and the heels to the buttocks.   In this manner she lay du-
ring the whole time while she was awake ; but as soon as she
fell asleep, the limbs were stretched out into  an easy, natural
posture.    She  slept well in the night, but the  moment she
awoke, the limbs were drawn up into their contracted condition.
If an attempt was made to extend them, great and  continued
force was required,  until they were brought nearly to the ex-
tended position, and then the complete extension took place
with a sudden  jerk.  They now remained in this  extended
position for a few seconds, when they were  by another sud-
den and painful jerk thrown back into their  contracted state.
This young lady had also occasional  spasmodic affections of
the arms, and of  the muscles  of the  neck;  but these  were
transient, and there  was no dimunition of muscular power in
the arms.   There was  considerable uneasiness of the back,
but nothing could be discovered by examination of the spine.
Both cases continued in the state which I have described  for
nearly six months, and then got entirely well.   The treatment
consisted chiefly of  free and continued purging with tonics,
and antispasmodics, topical bleeding  and repeated  blistering
on the spine.  In the elder of the two, one of the blisters led
to the formation of a large and troublesome carbuncle on the
spine, and this seemed to accelerate the cure.
   I do not know whether the following case  ought to be  re-
ferred to this class ;  it excited my attention, as a very remark-
able affection at the time when it occurred,  and I have not
seen another exactly resembling it.   A gentleman  aged 34,
of a slender make and very active habits, was affected in the
summer of 1815 with numbness and diminished sensibility of
all the extremities.   In the inferior extremities, it  extended
to the tops of the  thighs, and  sometimes affected  the  lower
parts of the abdomen ; in the superior extremities, it never ex-
tended above the wrists.  There was along with it  a diminu-
tion of muscular power.   He could walk a considerable dis- 
CONCLUDING  OBSERVATIONS.           335
tance, though he did so with a feeling of insecurity and un-
steadiness ; but he could not in the smallest degree perform
swch motions as are required in running, leaping, or even very
quick walking.   He was  in  other respects in  good health.
Various remedies were employed, without benefit; evacuations
and spare diet seemed rather to be hurtful.  He had continu-
ed in this state which I have described, for about two months,
when he determined to try the effect of violent exercise.   For
this purpose, he walked as  hard  as  he  was able, five or six
miles in a warm evening, and returned home much  fatigued,
and considerably heated.  Next  morning he had severe pains
in the calves of his legs, but his other complaints were much
diminished, and in a few days disappeared.   He has ever since
enjoyed very good health.

   These anomalous affections occur under other modifications
considerably different from those which I have now described.
I received from my friend, the late Dr. Monteith of Glasgow,
a very interesting account of two cases which occurred to him
under a very aggravated form.  One of these, a lady, aged 22,
was  at first affected with violent  headach, accompanied by a
sense of tension in  the head, and strong throbbing in the ca-
rotids, temporal arteries, and throughout the head ;  the  pulse
120.  Large and repeated bloodletting  was employed for the
first ten or twelve days, until she was "pale as paper," and
exceedingly enfeebled,  but  without  any relief.  After four
weeks, she became affected with  violent pain in  the lower ex-
tremities, which were drawn up  and could  not  be  extended,
the thighs being drawn up to the abdomen, and the legs bent
back upon the thighs ;  and every exacerbation of the headach
was  followed by an increase of irritation,  pain and  retraction
of the limbs.  The headach was chiefly referred to a spot upon
the left  parietal bone, where she  had received an injury by a
fall three months before.  A variety of practice was employed
with very little benefit: and her  only relief Was from blood-
letting,  and large doses of laudanum, of which she sometimes
took 500 drops in the course of a night.   Mercury  appeared
at one time to be productive of some benefit; the effect, how-
ever, was only temporary, though she went through  repeated
courses of it.   She used  prussic acid  to a great extent, the
warm bath, and a variety  of other remedies with very little
benefit.   At  the end of about three years, the  limbs for the
first  time became so free from pain  and irritation as to bear 
336        PATHOLOGY  OF THE SPINAL CORD.
applications with the view of remedying the stiffness of the
joints;  and, at the end  of about  three years more, she was
gradually restored to perfect  health.   This lady was not for
an hour free from headach for three years, but  besides this
constant pain, she was liable to violent  exacerbations of  it,
lasting from a few days to  several  weeks.   During  these at-
tacks the pulse became very strong and jarring, and the face
flushed  and swelled ;  and the only relief  she  obtained was
from repeated bloodletting, so that in the course  of her illness
she was bled from the arm ninety-eight times, besides frequent
topical bleeding by leeches and cupping.
  The other patient was a young lady of 17, whose complaints
also began with violent headach, for which she  underwent a
great variety  of treatment for upwards  of twelve  months,
without  any permanent benefit.  On the  contrary about the
end  of this period,  the  pain rather increased,  and she was
confined to bed in  a state of extreme exhaustion,  and suffering
from constant and intense headach.   Soon after, she first com-
plained  of  pain  in the spine, and  this  was speedily followed
by a sudden attack of most  excruciating pain  in both lower
extremities, extending over every part of them, and accompa-
nied by  such increased sensibility that  she could not bear the
weight of the bedclothes  upon them, and the slightest touch
with the  finger made her scream.   There was also tenderness
and morbid irritability of the trunk and upper extremities, so
that she  could not allow the arm to  remain  fully extended
during the  short time of feeling her  pulse.  From  the com-
mencement of this affection of the  limbs, they began to  be
powerfully  retracted,  and after a short time they were drawn
up  close to the body; and there was severe pain  extending
along the whole  course of the spine,  where, however, no dis-
eass could  be  discovered on examination or by pressure. She
now became much emaciated, pale  and debilitated;  the head-
ach was  rather relieved, but the limbs continued in the same
state, and the slightest  touch upon them, or the most gentle
attempt to extend them, gave such violent pain, that, for eight
months,  Dr. Monteith said,  she was not moved in bed six
inches.   At the erid of four years, this lady began to improve,
and to get  out of bed a little daily;  but at this time her legs
were so  much  bent upon the thighs, and the knees so rigid,
that no force could bring them to a right angle.   At the end
of three  years more, Dr.  Monteith's report of her was, that
she could walk a short way, and was progressively improving, 
CONCLUDING  OBSERVATIONS.
337
so that he entertained sanguine hopes of a complete recovery.
I visited this lady along with Dr. Monteith  in the course of
her illness, and I certainly never saw a case which gave me
more the impression of deep-seated and hopeless disease.
  The history of  these cases conveys a more  distinct impres-
sion of this extraordinary affection than could be given by any
description.   Other varieties of the symptoms were observed
in some of the  other  cases which  occurred to Dr. Monteith,
particularly long-continued' and uncontrollable vomiting, fits
resembling epilepsy and catalepsy, palpitations and  various
irregular actions of the heart, and a strong and painful pulsa-
tion extending  along  the  whole course of the spinal cord.
There were also irregular attacks  of fever, fits of colic, and
severe spasms in  the  abdomen, which were relieved only by
large opiates.   There was in general a remarkable aversion
to light, and one of his  patients lay in a state of almost total
darkness for more than a year.   In another patient, a lady of
30,  the arms were affected, but  not so severely as the lower
extremities.   This lady was  confined  to bed for two years,
and then recovered perfect health,  which she  had  enjoyed for
five years at the time  when I received this account.   In an-
other there was such incessant vomiting that she retained no-
thing in the  form of food, drink, or medicine, for six weeks.
In this  case  the  vision was also  very much impaired,  and
twice suspended for a very considerable time.  Nothing was
to be  discovered  about  the spine in any of these  cases,  and
the  pain in  the  spine was not increased by pressure, but it
was very much increased by  motion, or by attempting a sitting
posture.   In the treatment, temporary benefit was experienced
from bloodletting, very large opiates, and warm bath ;  but,
upon the whole, the disease seemed  gradually to wear  itself
out, without any mode of treatment having a sensible effect in
arresting its progress.    Even after considerable improvement
has taken place, the disease  is apt  to  relapse  from very slight
causes.   In one  of Dr. Monteith's cases, a cure was so far
accomplished in eighteen months, that a drive for a short way in
a carriage was then recommended;  but this produced a  relapse,
which lasted another year, and was fully as violent as the first.
  This  affection has been described by Dr. Burns of Glasgow;
and he mentions some other symptoms as occasionally attend-
ing it in his observation, such as attacks of  dyspnoea, resem-
bling  croup, temporary  loss  of speech, and  of the power of
swallowing, and  temporary aberration  of mind.   He agrees 
338         PATHOLOGY OF THE SPINAL CORD.

with Dr.  Monteith, in regard to the tedious  and untractable
character of the disease, and confesses, that,  " in most cases,
he has not seen  decided advantage from  any medicine, be-
yond what was required for symptoms as they arise, time ap-
pearing the chief remedy."  I find an analogous affection
described by Dr.' Guerin of Mamers, in a tract " Des Irrita-
tions Encephaliques et Rachidiennes."   One of his patients,
a young man of 16, had first attacks of palpitation and difficult
breathing, then violent pains in the upper part of the abdomen,
and, after six  months,  attacks  of loss  of recollection, with
convulsive motions of the arms,  grinding of the teeth, and vi-
olent palpitations of the heart.  These  attacks continued  to
recur at uncertain periods;  and, during  the  intervals, he did
not  entirely recover, from the effects of them.  He continued
depressed and incapable of any mental exertion, unable  to
bear the least light or noise, and the attacks were excited  by
any exertion or  mental  emotion.   The  patient continued  in
this state for upwards  of four years, and then gradually and
completely  recovered.    The principal remedies employed
were purgatives, topical bleeding,  prussic acid, and vegetable
diet.   In another case, very similar, in a  young man of  20,
he found  benefit from the use of cold effusion.
   I have frequently seen in young females a slighter affection,
in which  there was pain referred to various parts of the spine,
sometimes chiefly to the lower part of it, and  sometimes ex-
tending upwards and downwards  along the whole course of
the spine.  There was generally some degree of weakness of
the  limbs, with great  disinclination to walking,  sometimes
 with spasmodic twitching of the toes, especially in the night-
time.   I have treated such cases by topical bleeding and blis-
 tering, without  benefit; and I have generally found the most
 effectual  treatment to be regular but  moderate purging and
 sea-bathing.

   Attempts have been made to explain  these singular cases,
 by the doctrine of  spinal irritation.   But it may,  perhaps, be
 doubted,  whether this conveys any definite notion, or whether
 it is not to be considered as a gratuitious  principle, assumed
 so as  to answer  to the phenomena, rather than deduced from
 observation.   When we find, along with the complaints now
 mentioned, symptoms distinctly referable to the spine, as pain
 or tenderness on a particular spot, it is fair to consider this as
directing our attention  to an important seat of disease;  but 
CONCLUDING OBSERVATIONS.
339
there is no doubt that these affections often  appear, without
any symptom that can be referred to the spine, and in many
cases with sources of irritation,  distinctly referable to other
organs.  A gentleman, about whom I was  consulted some
time ago, had a severe and long-continued attack of nephral-
gia, which  was at last relieved by the passage of a calculus;
but such a degree of inflammatory action had been excited,
that, for  several weeks after the violence  of  the attack had
subsided, he discharged purulent  matter in his urine, in large
quantity.   In the course of the complaint, and about the time
when the violent pain, which was in  the region of the left
kidney, was beginning to  subside, he was affected  with diffi-
culty  of swallowing, a sense of constriction in the oesophagus
and the pit of the stomach, and spasmodic affections of  both
upper and lower extremities, and of the left side of the face,
closely resembling tetanus.  These continued in a greater or
less degree for eight or ten days.
  But it  is chiefly in females that  these anomalous spasmodic
affections are met with ; and in  these, one of  the most re-
markable features of them, is the connexion which they have,
even.in their most aggravated forms, with the state of men-
struation.  The following case will illustrate this in a striking
manner, and at the same  time exemplify some of the various
forms which are assumed by these singular affections.

  Case  CLVIIL—A lady, now  aged 28,  in the year 1823,
was first  affected with numbness and  partial loss of power of
the right arm and leg, and some time after had slight difficulty
of articulation.- These  symptoms subsided under  the usual
treatment, and returned after some months, when they affected
the legs and arms of both sides, and  had more of the charac-
ters of chorea.   After another interval of several months, she
became'liable to attacks of blindness, which were occasioned
by a falling down of the upper eye-lids, so that she could not
raise them; and when they were raised by the hand, the eyes
were found to be distorted upwards.   These attacks generally
continued for  several weeks at a time, and were  relieved by
cupping on the temples.
  With these symptoms the two first years of her illness pass-
ed.   In the third year she was affected with convulsive ac-
tion of the muscles of the  back,  and involuntary twitches of
the legs and arms, producing convulsive motions of the whole
body, which it is impossible to describe.  These were  much 
340
PATHOLOGY
OF THE SPINAL  CORD.
  increased by touching her, especially on any part of her back ;
  also by laying her upon her back, or even by approaching her
  as if with the intention of touching her.   At one time there
  wTas difficulty of deglutition,  so that attempts to  swallow pro-
  duced spasms resembling tetanus.  At other times, after lying
* for a considerable time quiet, she would  in an instant throw
  her whole body into  a kind of convulsive spring, by which
  she was thrown entirely out of bed; and in the same manner,
  while sitting or lying on the  floor, she would throw  herself
  into bed, or leap on the top of a wardrobe fully five feet high.
  During the whole of these symptoms, her mind continued en-
  tire, and the only account she could give of her extravagance,
  was, a secret impulse which  she could not resist.
     After a considerable time  these paroxysms ceased, and she
  was then affected with convulsive motions of  the muscles of
  the upper part of the back and the neck, producing a constant
  rotatory motion of the head.   This sometimes continued with-
  out interruption night and day for several weeks together, and
  if the head  or neck were touched, the motion was increased
  to a most extraordinary degree of rapidity.  During the attacks,
  she could not sleep,  except in the sitting posture, the motion
  continuing during this imperfect sleep, though in a more mo-
  derate degree;  but if she happened to slip down, so that her
  head touched the pillow, she  instantly awoke with a severe
  convulsive start, and  the motion was increased to the greatest
  degree  of rapidity.   These paroxysms were relieved by no-
  thing but cupping on the temples to the extent of 10 or 12
  ounces, when the affection ceased in an instant, with  a gene-
  ral convulsive start of the whole by.   She was then immedi-
  ately well, got up, and was  able to walk about in good health
  for several weeks,—when the same  symptoms returned, and
  required a repetition of the same treatment.  Sometimes from
  the violence of the motion of the head, it was impossible to cup
   her on the temple.  In  this  case, the cupping was  applied
   first on the back;  and by this, the motion was  so far moderat-
   ed,  as to allow it to be applied on the temple, without which
   the paroxysm was never removed.  Bleeding from the arm to
   the extent of faintness  only moderated it for a time,  but  did
   not remove it.   Another very singular feature  of the affection
   was, that it subsided fully only when it went off in an instant,
   with a sudden  convulsive start of the whole body: when it
   subsided gradually, as under the influence of  large bleeding, 
               CONCLUDING OBSERVATIONS.            341

it returned as soon  as  the faintness from the bleeding was
removed.
  The affection went on in this manner, with intervals of tole-
rable health of a few weeks' duration, for about four years, be-
sides the two years formerly mentioned.   The  longest inter-
val was one  of  about  three  months, but even during these *
intervals various  convulsive motions  were excited  by slight
causes.   Menstruation  was all along extremely irregular and
very scanty, and the bowels were torpid.   She was of a pale
and bloodless aspect from the frequent bleedings, but not re-
duced in flesh.   I saw her only at an  advanced period of the
disease,  along with Mr. Gillespie,  who had watched  her
through  its whole  progress,  and by  whom every variety of
treatment had been  employed with the utmost assiduity.
  At last, in the  spring of 1829, we found her under a severe
paroxysm of the rotatory motion  of the head ;  when it was de-
termined to allow the attack  to take  its course, and  to direct
our attention entirely to the menstruation.  With this view she
began to take three grains of sulphate of iron three times a
day, with two grains of Barbadoes aloes,—the aloes being af-
terwards diminished according to the state of the bowels.  She
went on with this for nearly three weeks  ; the convulsive mo-
tion of the  heacf continuing  without intermission night  and
day.   At length, in the middle of the  night, the paroxysm
ceased in an instant, with  the same kind of convulsive start
of the whole body with which it used to cease after  cupping.
At the same instant menstruation took place in a more full and
healthy manner than it had  done for many years.   She has
continued from that time free from any return of the affection.

   I  conclude this  subject with the following  case,  which
shows another form of this affection.   If we were required to
give a name to this modification, we could probably call it no-
thing but a very  aggravated form of hysteria.

   Case CLIX.—A young lady aged 15, in October 1828,
was thrown from a horse, but did  not appear to sustain any
injury except a contusion of the arm, and she did  not com-
plain of any thing else for a week after the accident.  At the
end of the week she fell asleep  in her chair one evening, and
 awoke in a state of incoherence, talking in a wild, extravagant
 manner, and appearing totally unconscious of the presence of 
 342        PATHOLOGY OF THE SPINAL CORD.

 those who were  about  her, and  entirely occupied with  her
 own hallucinations.  This condition continued in a greater or
 less degree for three weeks, notwithstanding much active
 treatment by bleeding,  purgatives, &c.    The bowels were
 throughout remarkably torpid.   She  then began  to recover,
' and went on in a state of progressive improvement for about
 three weeks, when one evening she fainted, and on recovery
 was found to be in the same state of incoherence as before.—
 This paroxysm continued] a fortnight, and was succeeded by
 another fortnight of convalescence, when the affection was re-
 produced by the patient being told of the illness of a near re-
 lative.
    During the  paroxysms she generally complained of intense
 headach, which was chiefly referred to the occiput;  the pulse
 varied from 90 to  120 ; the tongue  was white ; the bowels
 torpid and motions unhealthy; her nights were sleepless.  Af-
 ter the third of the  paroxysms  now  mentioned,  her conva-
 lescence was less perfect than formerly, there being generally
 a  good deal of excitement in  the evening, and very restless
 nights.  In the end of January 1829, after much previous ir-
 ritation, she fell into a  state of coma, with  flushing.  This
 continued several days,  and was succeeded by a state resem-
 bling catalepsy; the eyes  being  continually fixed in one di-
 rection but without perception ; total unconsciousness of  any
 thing that was done about her ; and the jaws so firmly locked
 that she swallowed nothing for several days.  The jaws then
 gradually relaxed, and she  recovered  the power of  swallow-
 ing ; after several days more she began to speak, after having
 spoken none for 13 days, and then went on gradually improv-
 ing for some weeks.  The comatose state then returned,  and
 was succeeded as  before  by the cataleptic,  the jaws  being
 again rigidly contracted, and the under lip drawn between the
 teeth so as to be wounded; the face  and neck were flushed
 and turgid. This attack subsided  after bleeding, &c, and
 was succeeded by cataleptic paroxysms  of a slighter kind,
 which were excited by various causes, such as the sight of a
 stranger or any degree of mental irritation.   In these attacks
 she became suddenly silent and motionless, the eyes open, but
 fixed  and insensible, with total unconsciousness of  every
 thing;  the hands clenched and  the  arms drawn towards the
 body.   She continued in this state from a few minutes to half
 an hour, and generally came out of it with a scream and with-
 out any recollection of the attack,  or of the circumstance 
CONCLUDING  OBSERVATIONS.
343
which had  excited  it.   In the middle of March she became
again incoherent and unmanageable, and this alternated with
the cataleptic attacks till the middle of April, when a new set
of symptoms commenced.  While lying in the cataleptic state,
she would  suddenly, and by a convulsive  motion,  raise her
body into a sitting  posture, the head projected forward, the
tongue protruded, and the countenance  much distorted; the
hands clenched and firmly pressed on each side of the trachea.
During these attacks respiration seemed nearly suspended for
some minutes, and  in her  convulsive efforts to breathe, she
sometimes  raised herself into a standing posture, and required
the care of several  attendants to  prevent her from throwing
herself out  of bed.   These paroxysms returned frequently and
at short intervals, and were relieved only by bleeding from the
temporal artery.  After some time they ceased, and were suc-
ceeded  by  the  slighter cataleptic attacks  excited by va-
rious slight causes.  It was at this period of the complaint that
I first saw her along with two eminent medical men who had
the charge  of her;  from that time there was no return of the
violent paroxysms ; and there was a gradual improvement in
her general health, which could not be ascribed to any other
cause than  a change of  scene, and  sending  her regularly out
into the open air.    The attempt to do this at first excited the
cataleptic state, and she continued totally insensible the whole
time she was in the carriage.   But  we persevered, and this
gradually subsided,  so that she was soon able to take a long
drive without exciting it, but there was generally some recur-
rence of it before she returned home. The slighter paroxysms
Were still excited by the sight of a  stranger, or by any cause
of mental agitation.  During these her body became motion-
less, but without losing her balance, though  she  was sitting
on  a chair without leaning to the back of it,  and even in some
instances while she was standing. The eyes  were open, fixed,
and insensible; the arms  generally rigid, but sometimes re-
laxed, and the attack continued from a few minutes to half an
hour.  She was also seized occasionally, while walking, and
continued to walk on steadily, leaning on the arm of another
person, and even walking alone, and often came out of the fit
without  stopping.   She was also  repeatedly seized while
playing on the piano, and continued to play with perfect cor-
rectness, but repeating a certain part of a tune, and  never go-
ing on beyond a particular point.  This she sometimes con-
tinued to do for ten minutes  at a time, during which period 
344         PATHOLOGV OF  THE  SPINAL CORD.
 she was totally unconscious of any external impression.   On
 one occasion she was playing from,the book a piece of music
 which was new to her, and had played a part of it when she
 was seized with the cataleptic attack.   During the paroxysm
 she continued to play this part, and repeated iUive or six times
 in the most correct manner; but when she recovered from the
 attack, she could not play it without the book.   The cata- •
 menia, in this case, were rather irregular, and at times scanty,
 but occurred in  a  very natural manner  several times during
 her illness, which, at the time to which this  account  refers,
 had continued ten  months. Soon after that time, she was re-
 moved to  a distant part of the country,  and  I have heard of
 her only occasionally.  But I understand she  has never been
 entirely free from the affection, though  the symptoms are  now
 in a slighter degree.
   I make no apology to practical men for these long details,
 as the affections are  of  a very uncommon kind, and as it is
 impossible to convey any idea of them by a general descrip-
 tion.   There are other modifications presenting very singular
 characters, but I must allude to them very briefly.  A young
 lady, whom I saw with Mr. William Wood, along with some
 symptoms resembling chorea, was liable to paroxysms, in
 which she screamed out the sound, echum, echum, echum,  with
 great rapidity, and in a  tone of voice  that  was  heard  over
 every part of a large house. These paroxysms often continued
 for one, two, and even three hours at a time, and occurred re-
 peatedly during the day, and sometimes  in the night.  They
 were excited by any sudden noise, or the sight of a stranger;
 and in the night-time not  unfrequently  by the striking  of a
 clock.   Her mind was  quite entire, but she  had no control
 over the affection, except that during the paroxysm she could
 change the sound when she was requested to do so, and  sub-
 stitute any other word that was suggested to her.   The affec-
tion went  on for many months, and then gradually subsided.
 We could scarcely say  that medical treatment was  of any
avail.   It consisted chiefly of a long-continued course of  pur-
 gatives.   For a considerable time after her recovery, though
 she was not at all affected by her disorder being talked of, she
 showed the greatest dread of the sound echum being repeated
 in her hearing.
  Another lady,  whom  I saw with  Dr.  Poole, was liable to
paroxysms of rapid and laborious breathing with a loud shrill
sound, and the  appearance of the  utmost distress, as in the 
                 CONCLUDING OBSERVATIONS.           345

 most aggravated form of croup.  They came on without any
 warning, when she was in perfect health, and if not relieved,
 continued for days together.   They were relieved by nothing
 but bloodletting, but in several instances, a bleeding of  three
 or four ounces was sufficient; and on one occasion, the attack
 was removed by a puncture of the arm,  when no blood was
 obtained, or only a few drops.   The  affection  subsided gra-
 dually after continuing to recur in this manner for more than
 a year.
   A case of much interest has  been  related by Dr. Follet of
 Namur. A strong country woman being much terrified during
 the flow of the menses, the discharge was suddenly suppressed.
 After  four  months, she experienced creeping  sensations',
 spasms, and involuntary motions of  the lower  extremities;
 and in the following month, the limbs became  forcibly bent,
 so that the heels touched the buttocks, and every attempt to
 extend them produced the most acute suffering.  These symp-
 toms continued five days, and then  subsided ; but they were
 renewed at the same period in the succeeding month, and sub-
 sided after the same duration,  but left a degree of paraplegia.
 The attacks were afterwards  moderated  by repeated topical
 bleeding, vapour bath, &c, but the  affection  continued  in a
greater or less degree for six or  seven months.  Menstruation
having then  taken place in a  full and healthy manner, her
complaints entirely disappeared.*

                    * Medical Gazette, vol, i.
44 
 
APPENDIX
TO
PART   FOURTH.
          OUTLINE  OF THE DISEASES OF  NERVES.

   Nearly allied to the pathology of the spinal cord, is ano-
ther subject of very great interest, the pathology of nerves.—
This subject is entirely in  its infancy, but the investigation
seems to promise very interesting results.   From what we al-
ready know, there is  every reason to believe, that nerves  are
liable to diseases analogous to the diseases of the brain and
of the spinal cord, which may affect them either in their sub-
stance or in their membranes, and are probably the source of
several diseases which are at  present involved in much]  ob-
scurity.
   In as far as this subject has hitherto been investigated,  the
following  may be considered as the principal  idiopathic  dis-
eases of nerves which have been observed.

   I. A uniform dark  red colour of the nervous substance,  oc-
cupying a defined space, perhaps an inch or two in extent.—
This was  observed  by Martinet,* in the median nerve, in a
case in which there had been violent pain of the fore-arm,
followed by palsy.  Repeated blisters removed the paralytic
affection, but, as soon  as the blisters healed, pain returned,  fol-
* Revue Medicale, Juin, 1814. 
 348      OUTLINE OF  THE  DISEASES  OF NERVES.

 lowed by palsy.  In a similar affection of the right sciatic
 nerve, accompanied by palsy of the limb, he found a diseased
 portion of nerve enveloped in a quantity of gangrenous cellu-
 lar tissue.   In another case he found a diseased portion of
 the crural nerve, which was an inch and a half in extent, en-
 larged  to about double its natural size.   This portion  was
 of  a  violet  red colour, and  strewed  throughout with small
 ecchymoses each about the size of a pin's head.

   II.  Serous or bloody effusion within the sheath of the nerve,
 penetrating  the substance of the nerve, and separating its
 fibres from each other.   This appearance was found by Mar-
 tinet in the sciatic nerve of  a  man who died of pneumonia;
 he had been affected with violent pain in the posterior part of
 his thigh, aggravated by the least motion* so as to make  him
 cry out.

  III. Pus effused in  the same manner among the fibrils of
 the nerve.  This was found in the sciatic nerve by  Martinet,
 in a man who died of disease both in the head and in the ab-
 domen, and who had been affected during  the latter part of
 his illness with violent pain in the course of the sciatic nerve.
 The cellular texture surrounding the diseased  portion of the
 nerve was also penetrated by pus. He found the same appear-
 ance in a young man who died of consumption, and who  had
 been affected for two months with lancinating pain,  and a
 painful feeling  of numbness  extending from the ham to the
top of the thigh.

  IV.  Ramollissement  of the nervous substance.—A man,
 mentioned by  Descot,* died in the Hotel Dieu, after he had
 been for six months blind  of one eye.   The optic nerve  was
found reduced through  half  its extent to a liquid matter of a
 white colour.

  V.  Ulceration of the  substance of the  nerve was observed
by Mr. Swan in connexion with a fungous ulcer on the leg.—
There had been such violent pain of the whole leg and thigh,
as to render amputation necessary, and, in many parts of the
limb, the nerves were found very much  enlarged.f
* Descot, sur les Affections Locales des Nerfs.
t Swan on the Local Affections of the Nerves. 
         OUTLINE OF  THE  DISEASES OF NERVES.      349

  VI.  Small tumors attached to nerves, and productive of
violent symptoms, have been described by various writers.  In
a remarkable case by Portal, a woman was cured of epilepsy
by the removal of one of these tumors from the thumb.   The
slightest pressure upon it  gave great pain,  and frequently
brought on an epileptic  attack.  The removal of such a tumor
however from one of the axillary nerves by Sir Everard Home,
terminated fatally; and the  safer mode of treating such affec-
tions appears to be to remove the portion of nerve entirely to
which the tumor is attached, when the nerve is so situated as
to render such an  operation  advisable.  Small tumors or tu-
bercles have also been found on internal nerves.  Sedillot found
one in the optic nerve, in a  case of  amaurosis;  and Berard
has described a black tumor as hard as scirrhus developed in the
substance of the diaphragmatic nerve.    The man had been
asthmatic, but he had also slight emphysema of the lungs.
  These tumors'are generally very small;  but there is another
species of  tumor which grows to a considerable  size.   One,
mentioned  by Mr. Pring,*  the size of a pigeon's  egg,  was
cut out from the arm, by dividing the nerve  above and below.
On  cutting into it, an expansion of the substance of the nerve
seemed to form an imperfect cyst, which contained a medulla-
ry and fatty matter, and the  filaments of the nerve were  con-
tinued over it.   There had  been great numbness and loss of
power of the arm, but it gradually improved after the opera-
tion.!

  VII.  Nerves have been found both very much enlarged and
very much diminished  in size; and  they have been in a few
instances found with  the  nervous  substance  destroyed, the
membrane  at the part  forming an  empty canal.   But these
points have not yet been sufficiently investigated.

  Few opportunities have as yet occurred of ascertaining the
condition of the nerve in those interesting cases of  local pa-
ralysis,  which  have  been  so beautifully illustrated by Sir
Charles Bell, and his lamented friend the late Mr. Shaw.  It
is probable that there is either an inflammatory action in the

  * Pring on the Nervous System.
  t Fob a very full and able  account of these tumors, and other diseases of nerves, I
refer to a paper by Mr. William Wood, in the Transactions of the Medico-Chirurgical
Society ofEdinburgh, vol. ii. 
 350      OUTLINE OF THE DISEASES OF  NERVES.

 nerve itself, or its coverings ; or that the nerve is affected by
 disease of some of the parts through which it passes.   The
 only case in which I  have had an  opportunity of examining
 the parts, since I was acquainted with the discoveries of Sir
 Charles Bell, was  in  a  woman about  40 years of age,  who
 died of organic  disease of the stomach.   About a fortnight
 before her death, she  was seized with  twisting of the mouth
 and paralysis of the orbicularis of the left eye. She had after-
 wards considerable indistinctness of speech, and, before her
 death, there was inflammation of the left eye, with an evident
 tendency to sloughing  of  the cornea.   A small hard tumor
 was felt under the ear, deeply seated betwixt the angle of the
 jaw and the mastoid process.  On dissection no disease could
 be discovered in the  brain.  The tumor under the ear was
 found to  be the size of a small bean, very firm, of an  ash-
 colour ; and, when cut across, it discharged thin puriform sa-
 nious fluid from  minute cells in its substance; it lay directly
 above the facial branch of the portio  dura; and there  was
 considerable appearance of inflammation  in the cellular struc-
 ture surrounding the nerve ; but I could not discover any de-
 viation from the healthy structure in the nerve itself.  I thought
 it was dimininished in size at the  place where the tumor lay
 over it, but in this I might be mistaken. In a case by Descot,
 connected with extensive suppuration and caries of the audi-
 tory portion of the temporal bone, a part of the  portio dura
 was entirely destroyed ; and in  a case by Billard, connected
 with an unhealthy abscess of the parotid  gland, the course of
 several of the nervous  branches was interrupted by destruction
 of part of their substance. An epileptic patient, mentioned by
 Serres, had inflammation followed by opacity of the right eye,
 loss of feeling of the conjunctiva, and insensibility of the right
 nostril, and right side  of the tongue.  He died  of an affection
 of the brain; and,  on  inspection, the fifth  pair of nerves, at
 its origin, was found yellow, softened, and reduced to a state
 almost gelatinous.

 • The important practical  application  of the  discoveries of
 Sir Charles Bell is,  that there may be paralysis of the muscles
 of one side of the  face, producing  distortion  of the  mouth
with inability to shut the  eye-lids,  without disease  of the
brain, and consequently without danger.  This  affection  de-
pends upon a disease limited to the portio dura of the seventh 
         OUTLINE OF THE DISEASES OF  NERVES.      351

nerve, and  may  be produced by inflammation of the ear or
the parotid gland, or tumors  compressing the nerve on any
part of its course.  The most common  example  of it seems
to originate in a kind of rheumatic inflammation produced by
cold,  especially by exposure to a current of cold air, as when
a person has sat long, or has  slept, opposite to an open win-
dow,  or has sat in his carriage with a cold wind blowing on
one side of his head.  It is to be treated chiefly by local re-
medies, as topical bleeding, blistering and the application of
warm water or steam.   In  this manner it is  often speedily
removed, but in some cases proves tedious, and does  not go
off entirely for several months.   The affection is of course
still more untractable, or even permanent, when it depends
upon  a permanent cause,  such  as  tumors compressing the
nerve, or destruction of a portion of the nerve by wounds or
extensive suppurations.   There is also a very formidable mo-
dification of it which depends upon disease of the temporal
bone.             •
   The character by which  these cases are distinguished from
paralysis depending upon disease of the brain, consists chiefly
in the sensibility of the parts remaining unimpaired.  The
loss of motion also is confined to the muscles of the face and
eye-lids, and does not affect those of the jaw.   These pecu-
liarities arise from the remarkable fact  demonstrated  by Sir
Charles Bell, Mr. Shaw, Mr. Mayo, and others, that the por-
tio dura of the 7th is a  nerve  of motion only, supplying the
muscles of the face and the orbicularis  of the eye,  but not
the muscles of the jaw ; and that the sensibility  of all  these
parts, and the motion of the  muscles of the jaw are  derived
from  the 5th,  which having  a double origin, is a nerve both
of sensation and motion.   An important distinction, however,
is to be kept in mind with  regard to the paralysis of the eye-
lids which occurs in these  cases, namely, that it is  the ina-
bility to  shut the eye that arises from the affection of the por-
tio dura of the 7th.   The dropping of the upper  eye-lid and
inability to  raise  it is a disease entirely  of a different  nature ;
it depends upon  an affection of the 3d  nerve,  and conse-
quently gives more reason  to suspect disease within the head.
   When, therefore, we  find  paralysis and distortion  of the
face,  with loss, of sensation of the parts, we  have reason to
suspect disease within the  head, the portio  dura of the 7th
and the 5th being both affected.   But when we have the para- 
  352     OUTLINE OF  THE  DISEASES  OF NERVES.

 lysis  without  diminution  of sensation, the  disease depends
 upon  an affection of the portio dura alone, and may be en-
 tirely  without  danger.   Such  cases, however, are  not to  be
 treated lightly, but the  cause of them  ought  to be carefully
 investigated;  for if there be  any reason to suspect that the
 affection depends upon disease of the  temporal bone, it may
 come  to be attended  with  danger by inflammatory action
 spreading inwards to the dura mater or brain.  There is an-
 other  modification also which requires to be watched  with
 anxiety, namely, when the  affection  is accompanied  with
 deafness ; as this gives reason to believe that both portions of
 the 7th nerve are affected,  and consequently to suspect an in-
 ternal  cause.   A very interesting case  of  this kind occurred
 some years  ago in the Infirmary of Edinburgh, under the care
 of my lamented  friend  the late Dr. James  Gregory.   Two
 years before his death, the man had  received a blow  on the
 right ear from  a stone, after which he had a purulent discharge
 from the ear for six months.   He then gipdually lost the hear-
 ing of that  ear, and about the same time the right side of his
 face became paralytic without any  diminution of sensibility,
 and the action  of the masseter and temporal muscles was un-
 impaired.   Without any farther change of  these complaints
 he died of phthisis in April,  1829.   The  petrous  portion  of
 the temporal bone was found most extensively destroyed, leav-
 ing an excavation which contained foetid purulent matter and
 portions of   dead bone.   The 7th nerve was traced from
 within  to the margin of  this  excavation, where it terminated,
 and the portio  dura, in  the same manner from without, the
 intermediate portion being  destroyed.   The parts of the nerve
that remained seemed entirely healthy.  The  brain and dura
mater were sound.  For some time before his death the pa-
tient suffered greatly from  dyspnoea, during the severity of
which  the ake of his left nostril were in strong and  constant
action, while those of the right were perfectly still.  If this
man had^ not been cut off by the  disease of his  lungs, the
affection of  the temporal  bone would  probably have  termi-
nated fatally in no long time, by inflammation of the dura
mater.
   I am indebted to Dr. Christison for a very important case
which  occurred to him in the Infirmary of Edinburgh in the
beginning of the year 1829.   The patient, a man of 30, was
seized  in the beginning of 1825 with acute pain, referred to a 
          OUTLINE  OF THE DISEASES OF  NERVES.      353

circumscribed spot on the left temple.  About a week after, he
had loss of speech  followed by coma.  He came out of this
with loss of the memory of persons, but gradually recovered,
and was  well in less than two months.  In the end of 1827,
he was again seized with pain in the temple, accompanied by
deafness  of the left ear and squinting  of the left eye.   The
deafness was permanent; the pain and squinting subsided after
three or  four months, but returned after two or three months
more, accompanied  by inability to close the eye-lids of the left
side, and considerable unsteadiness in his gait.   He was next
affected with pain and rigid contraction of the muscles of the
back of the neck and right shoulder ;  and these were followed
by retention of urine and  perfect paraplegia.  He had now
the usual paralytic state of all the parts supplied by the portio
dura of the left side, with deafness of the  left ear, distortion
of the left eye ir^svards towards the nose, and frequent spas-
modic twitches of the jaw, by which it was drawn to the right
side;  and he .died in a state of coma in February, 1829. On
inspection there was found  immediately behind  the left  tem-
poral fossa, a thickening of the dura mater with adhesion to
the arachnoid  of the extent  of  a half-crown piece.  There
was a similar adhesion, with very  great  thickening of the
dura mater above the pars petrosa of the temporal bone, and
the left side of the tentorium was also  very much thickened,
and presented on its inferior surface several tubercular eleva-
tions.  The thickening of the dura mater was greatest at the
part where it is perforated by the seventh nerve, and the sixth
nerve was also involved in the disease.  The portio mollis of
the seventh was, for a  few  lines previous to its entrance into
the meatus, of a reddish-grey colour,  and  nearly gelatinous
consistence; the portio dura  seemed smaller  than usual.   In
the substance  of the right hemisphere,  nearly on a level with
the ventricle, there was a tubercle the size of a  French bean ;
and there was  a small cyst in the right corpus  striatum.   In
the posterior cornu of the right ventricle, there was a peculiar
appearance, as if a portion  of it had been obliterated by adhe-
sion, cutting off a very small cavity about the size of a lemon-
seed,  which communicated  by a narrow opening with the ven-
tricle, and presented at each extremity a yellowish line or raphe
resembling a cicatrix.   No  appearance of disease could be
detected  in the contents of the spinal canal.
  This case is one of great  interest, besides the point which
                            45 
354      OUTLINE OF  THE DISEASES  OF NERVES.

it is here introduced to  illustrate.   In  particular, ii  presents
a most important example of chronic inflammation of the dura
mater, affecting three distinct portions  of it, and accompanied
by three distinct classes of symptoms.   The intense and long
continued pain of the left temple, which was a prominent fea--
ture of the case at various periods, appears to have been con-
nected with inflammation of a defined portion of the membrane
in that situation.   The remarkable affection of the functions
of the seventh nerve, we  may distinctly refer to the  diseased
condition of the same membrane where it is perforated by the
nerve;  and the distortion of the eye inwards, from  paralysis
of the abductor muscle, we trace to the sixth nerve being in-
volved in the  disease.   No cause  appears to  which we can
refer the paraplegia, except the disease of the tentorium, no
morbid appearance having been discovered in the spinal cord
or its membranes after the most careful examination.   I have
formerly referred to certain difficulties in the pathology of pa-
raplegia, and the obscurity attending those  cases in  which it
has been ascribed to disease within the head, from the spinal
cord not having been in general examined.*  Dr. Christison's
Case, therefore, is one  of much importance in this inquiry.

   The functions  of the 5th nerve, as has been mentioned, ap-
pear to be, to  give sensation to all the parts  about the face,
and motion to  the muscles of  the jaw ; and a variety of sin-
gular phenomena arise from affections  of this nerve,  or parti-
cular branches of it.  Thus, in the  organs of sense, there may
be  loss of common sensation, without any affection of their
proper senses depending upon their peculiar nerves.   A young
lady, mentioned by Sir Charles Bell, lost entirely sensation in
the ball of the  eye, without any diminution  of vision; and
there have been several instances Of the membrane of the nose
becoming insensible to common stimuli, while the smell was
little impaired.   In the  same  manner, there  may be loss  of
sensation in any limited part, from  disease or injury  of a par-
ticular branch of the 5th, as in a striking case  mentioned by
Sir Charles Bell.  A gentleman, after  having a grinder very
awkwardly extracted from the lower jaw, on putting a tumbler
to his lips, to  rinse  his mouth, exclaimed, "You have given
me a broken  glass."  He had lost entirely the sensation  of
* See page 222. 
          OUTLINE  OF THE DISEASES OF NERVES.      355

half the lip, from destruction of the branch of the 5th, which
passes along the lower jaw, and the affection was permanent.
The motion of the parts, depending on the portio dura of the
7th, of course was unimpaired.*
  A remarkable  circumstance  connected with the  affections
of the 5th nerve, is the tendency to inflammation and slough-
ing in parts which have lost their sensibility,—particularly in
the eye.   A very instructive case of this kind occurred to my
friend Dr. Alison.  The patient had loss of common sensation
on the left side of the face, the  left nostril, and left side of the
tongue, with insensibility of the ball of the eye, and occasion-
al bloody discharge from  the left nostril; and was liable  to
attacks of pain  occasionally accompanied with fever, during
which  the pain was chiefly referred to  the  insensible parts.
There were frequently  attacks of inflammation of the left  eye,
with dimness of the cornea, which were relieved from time to
time by the usual antiphlogistic means ; but at the end of two
months, a line formed round the base of the  cornea, which  at
length sloughed out, and the contents of the eye were entirely
discharged.   The muscles  of the left side of the jaw were pa-
ralytic, and felt quite flaccid when the patient chewed or clench-
ed the jaws, but the motion of the muscles of the  cheek was
unimpaired.   After the destruction of the eye, the  paralytic
symptoms remained stationary for a year or more; there  was
then a violent return of headach with fever, and death in a
state of coma after an  illness of a fortnight.  On inspection,
there was found  considerable ramollissement of some of the
central parts of the brain.   The 5th nerve of the left side, on
being traced  backwards from the gangloin,  was found, close
to the gangloin, to be of a very dense texture, but beyond this it
was much wasted, and at its junction with the tuber annulare^
nothing but the membrane seemed to  remain. In another case
of Dr.  Alison's, there  was loss of sensation of the left side
of the  face, followed  by inflammation and  sloughing of the
eye-ball;  after which  the sensibility of the  parts  returned*
The patient  was,  before  the   appearance  of these  symp-
toms, and has since  continued, liable  to severe headach
and epileptic fits.  The loss of  sensibility continued about six
months.
* Sir Charles Bell's Lectures, as reported in the Medical Gazette, vol. i. 
356      OUTLINE OF  THE DISEASES  OF NERVES.

  A remarkable combination of symptoms occurred in a case
related by Mr. Stanley.*   There was  hemiplegia of the left
side, without loss of sensation in the arm and leg, but in the
left side of the face both sensation and  motion were  entirely
lost.  In the left side of the  tongue, sensation was  lost, but
motion remained. The mucous membrane of the left nostril was
always of a deep red colour, and there were frequent discharges
of blood from it. The conjunctiva of the left eye became deeply
injected ;  this was followed by opacity and ulceration of the
cornea, and at last by total disorganization of the eye.  There
was total loss of hearing in the left ear.   There were frequent
attacks of erysipelas, which were entirely confined to the pa-
ralytic parts of the face.   The patient had been long affected
with headach, and at last died two months after the commence-
ment of the paralytic symptoms.  A tumor was found in the
left side of the tuber annulare, which compressed the origin
of the 5th and 7th nerves  against the base of the skull.  The
tumor was the size of a  walnut, of a firm consistence, and
brown colour, and extended into the left crus cerebelli.
  To affections of the nerves may probably be referred certain
obscure and severe disorders of a nervous kind, some of which
have supervened upon slight injuries, and  others have come
on without any obvious cause.  A young lady, mentioned by
M.  Verpinet,f received a slight wound with the  point of a
sword on the inferior and outer part of the fore-arm. It very soon
healed, but most violent pain continued in the fore-arm, wrist,
and hand, accompanied by convulsive motions of the arm, and
loss of the voluntary power of the wrist and fingers. The affec-
tion resisted every mode of treatment for two years, and then got
speedily well after the  application of the actual cautery to the
cicatrix of the original wound.  In  a lady,  mentioned by Mr.
Swan,! a slight wound on the  thumb was followed by numb-
ness, pain, convulsive motions of the arm, and spasms, which
occasionally affected  the  opposite  arm, and  sometimes the
whole body.   In  this case the affection seemed gradually to
wear itself out, though she was not  entirely free from  uneasi-
ness at the end of seven years.  A very violent  case of the
same kind, described by Mr. Wardrop,§ was cured after twelve
months by amputation  of the finger.  In  a similar  case  by
Larry, which followed a wound, a  portion  of the  nerve was

   * Medical Gazette, vol' i.              t Jour- de Med. vol. x.
   X Swan on Local Affections of Nerves.      § Med. Chir. Trans, voi. viii. 
         OUTLINE OF THE DISEASES OF  NERVES.      357

removed, without complete success, though  the  disease was
very much alleviated.    In a singular case by  Sir Everard
Home,* a gentleman received a violent sprain of his thumb,
by the weight of his body being thrown upon it, in saving him-
self when nearly thrown off, by a sudden motion  of his horse.
He was afterwards liable to paroxysms, in which his thumb
was first bent in towards the palm of his hand; a spasm then
took place in the muscles of the arm, after which he  became
insensible, and continued so for about  a quarter of an  hour.
The attacks returned frequently in the arm, but it was found
that the pressure of a tourniquet prevented the insensibility.
A nerve in this case was divided without success.  The tour-
niquet lost its effect in arresting the spasms, and he died sud-
denly after three months, but there was  no examination of the
body.
  In  the Medical and Physical Journal, Mr. Jeffries has  de-
scribed a remarkable case of a violent  neuralgia of the face,
which was cured by the extraction of a small fragment of china,
which had been lodging, there for fourteen years ; and M. Des-
cot mentions a case in which  a  severe  affection  of ten years
standing was removed by the extraction of a carious tooth.   A
young lady, mentioned by Mr. Pearson, was seized without any
obvious cause, with pain in the thumb, accompanied by a mor-
bid sensibility of the part; the affection gradually spread over
the arm, and was accompanied by loss of nearly the whole
muscular power of the extremity,  with  morbid sensibility of
the integuments, and a strong  contraction of  the fingers, so
that the points of the nails were forcibly pressed against the
palm of the hand.  The fingers were not under the control of
the will, and every attempt  made to extend them  was accom-
panied by insupportable pain.   The joint of the elbow was
also contracted, and voluntary motion was  nearly lost over the
whole extremity.  It was also very much  diminished in size,
while the morbid sensibility of it was inexpressibly distressing.
After  some  time the other arm was slightly  affected in  the
same  manner, and she had  likewise pain and great debility of
both the lower extremities.   After this affection had continued
about a  year, it got well under the use of  a  liniment com-
posed of olive oil, turpentine,  and sulphuric acid.  This pro-
duced most severe erysipelatous inflammation, which, begin-
* Phil. Trans., 1801, 
 358      OUTLINE  OF THE DISEASES OF  NERVES.

 ning upon the affected arm, extended  afterwards over the
 whole body.*
   Little has hitherto been done on this curious and interesting
 subject, but it certainly promises most important results, when
 it shall be more extensively cultivated.   For we  have every
 reason  to believe, that both the nerves themselves, and the
 investing membrane, are liable to affections which may be the
 source of many obscure diseases.  It is now upwards of twen-
 ty years since I first saw a girl,  aged at that  time  about  18
 months, and previously enjoying excellent  health.  She had
 been left for some time sitting upon damp grass, and was im-
 mediately seized with fever, accompanied by such a degree of
 oppression as led to  an apprehension of an affection of the
 brain.  These  symptoms, however, passed  off in  a few days,
 and,  upon her recovery from  them,  it was found that she was
 entirely paralytic in the right lower  extremity.   She has from
 that time enjoyed uninterrupted health,  and is now a tall and
 strong  young woman, but  the right lower extremity has con-
 tinued  entirely paralytic.   It is also a great deal smaller than
 the opposite extremity, and several inches shorter.   All the
 joints are  remarkably relaxed,  and  the  muscles flaccid; but
 there is no other appearance of disease in any part of it, or in
 the spine.  Some time ago I was  consulted  about a young
 man, aged 14, who had nearly lost the muscular power of the
 upper part of both his arms, accompanied by a most remarka-
 ble diminution of substance of the principal  muscles.  The
 deltoid and  biceps are  reduced to  the appearance of mere
 membranes, and the same affection extends,  in rather a less
 degree, to the muscles upon the seapula ; the muscles upon
 the fore-arm, however, are full and vigorous.   No disease can
 be discovered about the spine, and in other respects he is in
 perfect  health.   The  affection  has  come on  gradually, and
 cannot be traced to any cause.
   It  is impossible, I  think, to explain  such  cases as these,
 except upon the principle of local affections of nerves, which
 are at present involved in much obscurity.  There are various
 other affections which  ean  only be  referred to the same sub-
ject, and which present some very singular phenomena, though
 the facts relating to them have not yet been brought together in
 any connected form.  In the year 1828,1 was consulted about a
* Med. Chirurg. Trans, vol. viii. 
         OUTLINE OF THE DISEASES OF NERVES.      359

singular disease of this nature, which occurred in paroxysms,
and affected in the same  manner two individuals of one fa-
mily, a young lady of 25, and a young man of 22.   The lady
described the  attack in the following manner.  She was first
affected with blindness of  the right eye, which  came on gra-
dually as  if a cloud passed slowly over the eye;  about a
quarter of an hour after this, she felt  a numbness of the little
finger of the right hand, beginning at the point of  it, and ex-
tending very gradually over the whole hand and arm, produ-
cing a complete loss of sensibility of the  parts,  but without
any loss of the power of  motion.  The feeling of numbness
then extended to the right side of the head, and from this it
seemed to spread  downwards  towards the stomach.  When
it reached the  side of the head, she became oppressed and
partially confused, answered questions slowly and confusedly,
and  her speech was considerably affected; when  it reached
the stomach she sometimes vomited.   The feeling  of numb-
ness then began to subside, and as it went off, she  was seized
with violent headach, which continued for several hours, and
left her for a day or two feeble and languid.  The progress
of the feeling  of  numbness, from the little finger to the  sto-
mach, sometimes  occupied several  hours, and the common
duration of the whole paroxysm was about twenty-four hours.
The frequency of its occurrence varied from a few  days to se-
veral months ; she had been liable to it for several years, but
in the intervals betwixt the attacks she enjoyed perfect health.
Her brother, who was 22 years of age, was affected almost
exactly in the same manner, and he had been liable to the
paroxysms for many years.  He was a banker's clerk, and in
the intervals  between  the attacks,  enjoyed perfect health.
When  he felt the commencement of the attack,  he hastily
brought to a conclusion any business in which he happened
to be engaged,—gave distinct instructions to another of the
clerks in regard to the state in which he left the affairs of his
department; then walked  home, went to bed, and soon after
became insensible.   Next day he was in his usual health,
except a considerable degree of languor.
   These singular cases were  under the care of the late  Dr.
Gibson of Montrose, and they seemed to derive benefit from
a  course  of purgatives, followed by a course of  sulphate of
quinine, combined with small quantities of rhubarb.  In a far-
ther report received in 1829, Dr.  Gibson informs me that the 
360     OUTLINE OF  THE  DISEASES  OF NERVES.

affection had continued, but that the attacks had been less fre-
quent and  less severe; and that, on several occasions, they
seemed to have  been lessened in  violence and shortened in
duration by emetics.  In 1834  I learnt that  the young man
had entirely recovered ; but that the lady had  died of con-
sumption in 1832, and  had continued  liable  to  occasional
attacks  of  her peculiar headach almost to  the time of her
death.
   The affections of internal nerves present a subject of  still
greater  difficulty, and the observations that have been made in
regard to them are at- present far from  being satisfactory.—
Lobstein* thinks he has  ascertained the existence  of  inflam-
mation  of the great sympathetic nerve ;  and  to  this source he
refers many obscure diseases, such as, violent hysterical affec-
tions, sympathetic  affections of the heart, spasmodic  cough,
colica pictonum, angina pectoris, and many obscure affections
of the stomach and bowels.  In the same manner, he explains
the fatal effects which  are  produced by blows  upon the sto-
mach, and  the severe symptoms, both in the head  and in the
general system, which  often arise from  worms, and from other
disorders of the bowels.  In a lady who died of urgent vomit-
ing, with burning pain  in the spine and in the right hypochon-
drium, he found the semilunar ganglion in a state  of intense
inflammation, and  the  lower part of it  livid.  In a boy who
died with great oppression of the chest, and distension of the
epigastrium, supervening upon the retrogression of a  miliary
eruption, he found  deep inflammation of a part of the trunk of
the left  intercostal nerve, and of the ninth and tenth thoracic
ganglia.
   These speculations must  be  received with much caution,
especially as nothing is more precarious than morbid appear-
ances, consisting of mere change of  colour of parts, without
any of the actual results or terminations of inflammation.  We
must forbear to speculate where we have not facts before us,
but it appears extremely probable that there are diseases of in-
ternal nerves which may be the  source of  important  morbid
phenomena.  Descot exposed  the  par vagum upon the neck
of a dog, and bruised it on both sides slightly with a pair of
pincers  ; the wound healed favourably, but the animal was af-
fected with  general tremors, difficult  and laborious  breathing,
* De Nervi Sympathetic! Fabrica, Usu, et Morbis. 
         OUTLINE OF THE DISEASES OF  NERVES.      361

vomiting, great debility and wasting. The vomiting subsided,
and the other symptoms were diminished, but he had not re-
covered a natural state of  breathing, when  he was killed at
the end of three weeks.  The internal organs were all healthy.
The nerve on the left side,  where the injury had been inflict-
ed, appeared slightly increased in size, and was of a yellowish
colour; and that on the right  side appeared more decidedly
enlarged, highly injected, and  adhering to the neighbouring
parts.
46 
*
I
*• 
        ARRANGED  SELECTION  OF CASES,
Illustrative of the Principal Modifications of  Organic Dis-
  eases of  the Brain, intended to form a  Supplement  to
  Part III. of this  Treatise.
                        SECTION I.

First Class.—Lonq-continued headach, terminating at last by
               coma or by gradual exhaustion.
[See page  264.]
          Symptoms.
  Case I.—A woman of 35—fixed
pain in the back of the head—walk
tremulous and unsteady, like a per-
son balancing  a bufnen on  the
head—much throbbing in the head
—hysterical symptoms.  Remark-
able remission of all  the symp-
toms after the formation of an ab-
scess in  the  axilla; but the  pain
returned when it healed, and in-
creased  to  tremendous severity,
and with remarkable  remissions.
From two o'clock in the morning
till two in the afternoon she was in
the  greatest agony, lying with her
eyes closed—the eyebrows  con-
tracted—the hands clenched—and
the  head immoveable in one posi-
tion—unable to  bear  the least
noise, or to move a muscle.   Af-
ter two, P. M. the  symptoms gra-
dually remitted—she   took food,
and about nine fell asleep,and slept
till  two,  when the paroxysm re-
     Morbid Appearances.
  A tumor at the base of the cere-
bellum,  growing from both lobes
of it, and descending within  the
dura mater  into the  spinal canal,
as low as the sixth spinal nerve.—.
It was soft like foetal brain, and
seemed to grow out of the interior
of the cerebellum.  As it lay along
the spinal cord, it rested upon the
origin of the nerves, but did not in-
volve them  in its substance.—Dr.
Latham, Med. and  Phys. Jour.
July,  1826. 
364
SUPPLEMENT TO PART III.
          Symptoms.
curred.  As the disease advanced,
the interval  became  shorter,  and
for a fortnight before her death the
pain was constant—senses entire
to the last—palsy of  the  left leg
for three days before death—dura-
tion of the case fourteen months.

   Case II.—A man aged 40—vio-
lent pain in the back of the head,
ceasing at times, but returning,
and  accompanied  with vomiting,
and  always  referred  to the same
spot,  much   relieved  at different
times by bleeding and by saliva-
tion,  but  always  recurred with
great violence, and was referred to
a single point at  the  junction  of
the temporal and  occipital bones
—frequent vomiting—impaired vi-
sion.  Died suddenly  in one of the
attacks of pain—duration of the
complaint about a year.

   Case III.—A young man of 20
—violent pain of the  forejiead ;—
it occurred in  paroxysms wfyich
generally continued four days, and
were followed  by  intervals   of
partial  relief of  about the same
duration.   After  two years  died
suddenly in the night from convul-
sion.

   Case IV.—A man of 50—con-
stant pain of forehead, with fre-
quent vomiting.   Other functions
healthy.  Coma  for  three days
before  death.   Death in thn#e
months by gradual exhaustion.

   Case V.—A man aged  55—lan-
cinating pain in the  right side of
the head—aggravated at intervals.
After two months  coma and death.
Morbid Appearances.
  In the left lobe of the  cerebel-
lum, a tumor  an inch long and
ten lines in breadth, composed of
about nine alternate layers of  a
chalky matter, fluid albumen, and
a very firm matter with  the pro-
perties of albumen, which grated
under the knife.  It was enclosed
in a cavity which also contained a
tough glutinous matter,  and the
surrounding substance was like
rancid bacon.—Prof. Nasse App.
to  Germ.  Trans, of Dr.  Aber-
crombie's Papers on the Brain.
  A tumor the size of a pigeon's
egg, hard in the centre, and exter-
nally soft, in the substance of the
cerebellum, other parts healthy.—
Planque Biblioth. III. 348.
  A tumor two inches long arising
from the cella Turcica, covered by
the dura mater.  Ventricles  dis-
tended  with  serum.— Communi-
cated by Mr. William Brown.
  A mass as hard  as scirrhus,
four inches long, and between
two and three broad, in the sub-
stance of the right hemisphere, on
the outside of the thalamus.  In-
ternally it contained  small  cells
full of gelatinous matter.—Bouil-
laud Traite del Encephalite. 
        CASES OF ORGANIC  DI

          Symptoms.
  Case VI.—A boy of 14—severe
headach for  two  months—then
convulsion, followed by coma and
death on the 8th day.
  Case VII.—A man aged  35—
violent headach, which was some-
times so severe as to oblige him to
remain for a considerable time in
one posture, incapable of the least
motion—consumptive  symptoms
—death after seven months in a
state of complete marasmus.
  Case. VIII.—Man of 58—liable
for  15 years  to attacks of acute
pain in the right temple, extend-
ing over the right side of the head
and  face—first  attack  continued
three weeks—and it afterwards re-
turned in  paroxysms of very un-
certain duration, and at very irre-
gular intervals.  After fifteen years,
a more severe attack, which con-
tinued two months  and ended in
coma and  death.  For  some days
before death, had palsy of the left
side, and of the right eyelid.

  Case IX.—An officer aged  33
—slight pain  and confusion of the
head with impaired  appetite.  Af-
ter  ten weeks, nausea and pain in
the eye-balls.  He was then wound-
ed in the head—lost much blood,
and the bone exfoliated, and he
was much belter for more than a
year.  Then  headach—watchful-
ness—flushing—and ophthalmia.
Recovered aft«r three months, but
was never free  from headach.   It
gradually increased;  was  some-
times referred to a spot on the oc-
ciput, and sometimes through the
iEASES OF THE RRAIN.   365

     Morbid Appearances.
   A tumor the size of a walnut, of
 a rose-colour and a fatty consist-
 ence, behind the posterior part of
 the medulla oblongata;  another,
 smaller, in the left lobe of the  ce-
 rebellum.   Serous  effusion—dis-
 eased mesenteric glands—ulcera-
 tion of the small intestines.—Me-
 rat. Journ. de Med. torn. X.

   Three ounces of fluid in the ven-
 tricles,  a firm  tumor the size of a
 pigeon's egg in the upper and mid-
 dle part of the right hemisphere,
 enclosed in a reddish sac, internal-
 ly of a yellowish colour. A larger
 tumor of the  same appearance in
 the left lobe of  the cerebellum—
 extensive disease of the thorax and
 abdomen.—Merat, ut supra.


   On the outside of the right tha-
 lamus,  and on  a level with it, a
 a tumor in the  substance of  the
 brain of  a  reddish-grey colour—
 four fingers breadth in length, and
 two or  three in breadth,  partly
 hard, and partly in  cysts contain-
 ing a gelatinous matter.—Andral.
 Jour, de Phys.
   Three  ounces of fluid in  the
♦entricles—in the seat  of the pi-
 neal gland, a little to the right side,
 a tumor the size of a nutmeg—in-
 ternally it was like cheese, but or-
 ganized.   Ramollissement of the
 cerebellum.-fStr G. Blane, Trans.
 of a Soc. vol. ii. 
366
SUPPLEMENT TO PART III.
          Symptoms.                Morbid Appearances.
whole head.  Was much  aggra-
vated by motion, which produced a
painful jarring in his head, and
much increased by going to stool
—pain at last excruciating, with
numbness of the  left hand—then
sudden delirium—coma and death
in three  days—duration  of the
complaint three years.

  Case X.—A woman of 40—se-   A soft tubercular mass the size
vere shooting pain in the occiput  of a hazel-nut in the posterior lobo
—at first alleviated towards even-  of both hemispheres—left lobe of
ing—afterwards unremitted. Con-  the cerebellum almost destroyed
stant sickness, and afterwards vo-  by the softening of a similar tumor
miting  of   every  thing  taken.—  occupying its interior—substance
Death from gradual exhaustion in  of the  cerebellum  around it indu-
four months.                    rated.  Three ounces of fluid in the
                               ventricles.—Dr. Chalmers, Med.
                               and Phy. Jour. July, 1826.


  It is unnecessary to multiply cases  of this class, which pre-
sent little  variety in the phenomena.  In  a case  by Willis,
there was a tumor three inches broad adhering  to the mem-
branes at the side of th^e third sinus; and  in one by Saviard
there was, under the junction of the  lambdoidal and sagittal
sutures at the broadest  part  of the  falx, a  small triangular
piece of bone with very sharp  angles.   Where  these  angles
came in  contact with  the dura mater, it was livid and  dis-
charged a little  pus.  In a lady, mentioned by Borellus, there
was, near the torcular, a hard, rough, irregular mass of consist-
ence, with many sharp processes  and angles ;  and in a case
by Schenkius, there was a stony tumor like a mulberry in the
brain of a man who had suffered from long-continued and in-
tense headach, which left him no interval of ease day or night.
See also the cases formerly described under the head of tu-
bercular diseases of the brain, particularly cases LXXXIIL,
LXXXV., and XC, which exhibit examples of  organic  dis-
eases, with remarkable remissions  of the pain. 
CASES OF ORGANIC DISEASES OF THE BRAIN.    367
                        SECTION II.

Second Class.—Headach, affections of the senses, speech, or in-
                           tellect.
           Symptoms.
   Case XI.—A man aged 42—af-
 ter exposure to the sun by walking
 in  a procession without his hat,
 was seized with  headach, which
 became  intermittent,   and  was
 treated by bark.   After  six weeks
 it ceased, but left amaurosis. Then
 followed fever and death.

   Case XII.—A  man aged 47—
 headach and weight in the head,
 increased by stooping.  Began in
 May, 1816, and increased gradual-
 ly, notwithstanding copious  eva-
 cuations.   In August his sight be-
 gan to diminish,  with giddiness;
 in September, could only see ob-
jects in a very strong light;  in De-
 cember,  perfect  blindness—pain
 still constant and severe.  In the
 middle of January stupor and for-
 getfulness,  and died comatose on
 the 31st.

   Case XIII.—An officer who had
 seen much service—severe head-
 ach, which subsided  and  left a
 feeling  of tightness  across  the
 forehead.   After  six  or   eight
 months, blindness of the right eye,
 then blindness of the left.  Under
 the operation  of an  emetic,  the
 sight of the left eye was recovered
 for an  hour—afterwards perfect
 blindness  and  pupils insensible,
 but no other complaint, except dis-
 ordered stomach, and  frequent in-
 clination to vomit.  Death from
coma after  two years.

   Case XIV.—A man aged 30—
excruciating headach,  which com-
     Morbid Appearances.
  At the anterior part of the right
hemisphere, a scirrhous mass the
size of a nut, surrounded by exten-
sive ramollissement of the cerebral
substance—thalami sound—optic
nerves   shrivelled.—Cruvielhier
Nov. Bib. De Med. Nov. 1825.
  A tumor, the size of a large egg,
attached to the tentorium in such a
manner, that part of  it lay above
it and part below it, the falx like-
wise entering into its substance
above.  Internally it was firm, and
resembled the structure of the kid-
ney—-fotftr ounces  of fluid in the
ventricles.—Author's Notes.
  Four ounces of fluid in the ven-
tricles ; a tumor, the size of a hen's
egg, containing a  thick  purulent
fluiff, under the anterior part of the
brain, and interposed  betwixt the
optic nerves, which were much se-
parated by it from each other.  Be-
low it was attached to the pituita-
ry gland, which was very soft, and
enlarged to five or six times its na-
tural size.—Med. Trans, vol. v.
Dr. Powel.
  A tumor, the size of a large wal-
nut, projected from the lower part 
 368   CASES  OF ORGANIC  DISEASES OF  THE  BRAIN.

 menced after hard working in a  of the anterior lobe of the left he-
 hay-field—chiefly  referred to the  misphere. Internally it resembled
 forehead, from which it extended  an absorbent gland.  The greater
 over the left ear, but sometimes af-  part of the medullary substance of
 fee ted the right  side of the head  the left hemisphere was reduced
 also, and occasionally the neck—  to a soft pulpy state, and was of a
 more severe in the night.  After  light brown colour.—Med. Trans.
 six or seven weeks blindness,  at  vol. v. Dr. Powel.
 the end of two months, an apoplec-
 tic attack, and death in two days.

   In the other cases of this class the symptoms are nearly si-
 milar,—fixed pain in the head and gradual loss of sight,—the
 intellect being frequently affected in the advanced stages, and
 frequently  the speech impaired.   A case has been already de-
 scribed, in which there was blindness of one eye and loss of
 speech, in connexion with a cyst containing albuminous  mat-
 ter in the  posterior part  of  the  left  hemisphere—(See Case
 XCL, page 144.)   In a case by Platerus, fatal by gradual
 wasting, there was a tumor  larger than an egg, compressing
 the origin  of the optic nerves.  In one by  Drelincurtius, there
 was  a steatomatous tumor the size of a fist between the brain
 and the cerebellum.  In  this case there were  both blindness
 and deafness, and it was fatal suddenly by an apoplectic attack.
 In another, by the same writer, the pineal gland was  enlarged
 to the size of an  egg, and was of an earthy or stony structure.
 In a case by Bouillaud, with impaired sight and speech, and
loss of the memory of names, there was a tumor the size of a
large nut in the anterior part of the left hemisphere.
                       SECTION III.

Third Class.—Headach—affections of the senses and convul-
                           sions.

          Symptoms.                Morbid Appearances.
  Case  XV.—A girl aged 11—   A tumor the size of a  walnut
long liable to headach, with weak- rested  on the cella Turcica, and
ness of sight, and a peculiar ten- compressed the junction of the qp-
derness of the integuments of the tic nerves.  It was  composed of a
head.  In autumn 1814,  she  re- medullary substance of a yellow-
ceived an injury on the forehead ish colour, and was covered by a
from a fall, and from that time suf- thin and  delicate membrane.—
fered much from headach, with Communicated by  Dr. Hay. 
       CASES  OF  ORGANIC  DISEASES  OF  THE BRAIN.    369

           Symptoms.                  Morbid Appearances.
frequent epistaxis.  In the end of
December, the  headach increased
with fever, intolerance of light and
sound—squinting and  convulsive
paroxysms, which,  for some time,
recurred  every half  hour.    In
March,  1815,  she  improved  re-
markably,  and  for  nearly a year
continued better in regard to the
head symptoms, but affected with
scrofulous  sores on the neck and
on the leg.  In May, 1816, head-
ach increased, with impatience of
light and sound—squinting,  gra
dual failure of sight; at last blind-
ness in July.   She died  in Octo-
ber, her intellect having continued
unimpaired; remarkable acuteness
of hearing,  and  intolerance  of
sound continued to the last.

  Case XVI.—A young man  of    Four ounces of fluid in the ven-
15—deep seated pain in the head,  tricles ; on the left side of the pons
and after six  months  inarticulate  Varolii, a hard tumor the size ot a
speech.   Three attacks of convul-  bean ; surrounding substance soft-
sion, each often or fifteen minutes  ened, approaching to suppuration.
duration;  the last left palsy of the  -Coindet sur VHydrenceph. p. 98.
right side, which disappeared next
day.  Died comatose  in another
month, having  had  repeated con-
vulsive  attacks, intense headach,
impatience of light,  afterwards di-
lation of the pupils, deafness, palsy
of the eye-lids, very difficult articu-
lation, and some delirium.

  Case XVII.—A  servant  girl    Throughout  the  substance  of
long subject to headach, which, in  both hemispheres, and in the cor-
ner 19th year, became very severe,  pora striata, there were numerous
and occurred periodically, general-  tubercles the  size of peas.   They
ly once  in  four weeks  and some-  were externally hard, and inter-
times oftener.  In her 21st year,  nally contained a small cavity full
the headach became more violent  0f a thick greenish fluid. Twenty-
and permanent, with frequent yo-  one of them were collected—sub-
miting, and occasional fits of in-  stance of the brain healthy—cor-
sensibility.  She had then attacks  pora striata considerably softened.
of double  vision, and  afterwards  —Prof.  Nasse. ut supra.
convulsions,  which returned  at
first in five or six days, and after-
wards every second or third  day.
About three months after the com-
                               47 
370
SUPPLEMENT TO  PART III.
          Symptoms.
mencement  of the  convulsions,
she was one morning found dead
in bed.

  Case XVIII.—A woman  aged
19—Headach, vertigo, suffusion of
the eyes;  paroxysms, in which
she fell down insensible, without
convulsion.   They  attacked her
once in three weeks, and at each
time there were two paroxysms at
the distance of twelve hours;  af-
ter eight or nine months, these at-
tacks increased in severity.  She
had then loss of hearing, sight, and
smell, and her speech  and deglu-
tition were much impaired.  Soon
after this died apoplectic.

   Case XIX.—A man aged 24,—
severe    headach—watchfulness
and imbecility  of  the  head—
blindness of the left eye, and after
a month of the right   Convulsive
paroxysms which continued to re
cur for  six  months;  they then
ceased, and  he  died of pectoral
complaints.
  Case XX.—A child of 4 years
—unable  to  walk—articulation
very imperfect—intelligence very
deficient—deglutition  very  diffi-
cult, liquids swallowed often re-
turning by the mouth and  nose—
difficult respiration and frequent
convulsions—but was  full in flesh
—had been  in this state about a
year—died in six months more.

  Case XXI.—A woman aged 23
—After suppressed menstruation,
violent  headach, impaired vision,
and after  some time blindness.—
Repeated  convulsive attacks; af-
ter  one of  which she lost  her
speech for two days. Intellect en-
tire.   Died  comatose   after  four
months.
Morbid Appearances.
  Embedded  in  the  substance of
the right hemisphere, there was an
hydatid  three  inches  long,  and
two  broad, and  very vascular.—
Brain in other respects healthy.—
 Yelloly,Med. Chir. Trans, vol. ii.
  Extensive disease of the lungs j
much effusion in the brain; in the
substance of the left hemisphere, a
tumor larger than an egg, weigh-
ing fourteen drachms ; it was co-
vered by a fine sac,  and internally
was white, firm and uniform, re-
sembling coagulated albumen, but
harder.—Felix Platerus, Lib. I.
108.

   Corpora olivaria,  cms cerebelli,
and tubercula mammillaria in  a
state of cartilaginous hardness;
other   parts    sound.—Author's
N&tes.
  On the surface of the right he-
misphere there were three harden-
ed spots, each an inch in diameter.
They were the  surfaces of  tuber-
cular masses, which extended into
the medullary  substance of the
brain.  There was a similar tu-
bercle  in  the  substance  of the
hemisphere, and one smaller in 
CASES  OF ORGANIC DISEASES OF  THE BRAIN.    371
Symptoms.
  Case XXII.—A  lady aged 40,
ot a scrofulous habit—gradual fail-
ure of  memory, sight and hearing;
inarticulate speech; epileptic pa-
roxysms, at first once in the fort-
night, afterwards more frequent—
her gait feeble and tottering—died
in six months.  A year before her
death, she had been much stunned
by a fall down a stair.
   Case XXIII.—A man aged 26
—Severe headach ; most distress-
ing when lying  on the  left  side;
occurring in paroxysms with giddi-
ness.  After several months, pain
increased,  with impaired vision
and dilated pupil.  Paroxysms of
giddiness, with blindness ; loss of
speech, stiffness  of the  limbs du-
ring the paroxysms;  then double
vision ; violent pain  in  the neck,
with convulsive paroxysms, affect-
ing the muscles of the  neck, and
drawing the head  violently back-
wards.  Two months after this he
had numbness and spasmodic mo-
tions of the  superior extremitief.—
After seven or eight months died
suddenly in a fit resembling epi-
lepsy.

  Case XXIV.—A man aged 35
—Severe headach, and sense of
weight in the head for two years ;
copious epistaxis ; loss of the,sense
of smell; then frequent epileptic
paroxysms  for  two  years—died
suddenly.

  Case.XXV.—A man, (age not
mentioned)—severe headach, fol-
lowed by amaurosis and epileptic
      Morbid Appearances.,
 the surface of the left hemisphere.
 Slight effusion, in the ventricles.—
 Powel. Med.  Trans. V.

   A tumor, the  size of a small
 orange, lay on the pars  petrosa of
 the left temporal bone, inclining to
 the opposite  side, and producing
 great depression in the substance
 of the brain ;  the  seventh pair of
 nerves, and ihe branches of  the
 fifth pair were  compressed  and
 stretched by the tumor.  Internal-
 ly it consisted of a  soft, uniform
 substance, resembling the cineri-
 tious matter of the brain.—Com-
 municated by Dr. Hay.

  A hard tumor  two inches long,
 and an inch and a half broad, was
 firmly attached to the  tentorium,
 and imbedded in the posterior lobe
 of the left hemisphere.  It contain-
 ed an ounce of greenish pus, and
 the cerebral substance near it was
softened. Where  the tumor press-
ed against the occipital bone, the
 dura mater was  obliterated,  and
 the bone rough.   Two  ounces of
fluid  in  the   ventricles.—Clerk,
 Edin. Jour. VI. p. 275.
  Cerebral substance on the ante-
rior part of the right  hemisphere
was hard and callous, and  adher-
ed intimately to  the dura mater ;
on the left  side some extravasated
blood.—Morgagni, Epis. 9.


  On  the  inner surface of the
left parietal bone, there was  an
osseous spongy tumor, three inch- 
372
SUPPLEMENT TO  PART III.
          Symptoms.                 Morbid Appearances.
paroxysms, which occurred almost  es broad, and more than an inch in
daily.  He died  in an apoplectic  thickness.— Wepfer.
attack.
                        SECTION  IV.

Fourth Class.—Convulsions, without affections of the senses.—
                 Intellect sometimes impaired.
          Symptoms.                 Morbid Appearances.
  Case XXVI.—A man aged 60   An hydatid the size of a pigeon's
—Epileptic for six years, with loss egg, in the posterior  part of the
of memory.  Died suddenly.      right hemisphere.  It  contained a
                                yellowish fluid, which was partly
                                gelatinous.  The substance of the
                                brain under  it was hardened.—
                                Lancisi de Sub. Mort. cap. 11.
  Case XXVII.—A boy aged 16
months  formerly healthy,   was
seized  Vith an  attack of convul-
sion.   It affected chiefly his right
side, which was very strongly con-
vulsed. He had a second attack
on the evening of the  same day,
after which he  had fever, blind-
ness, and loss of the power of de-
glutition.  In this state he  con-
tinued  ten days,  when he had an-
other fit, and after this he gradual-
ly recovered his sight and degluti-
tion.   From this time there was a
degree  of paralysis  of the  right
side, but in other respects he en-
joyed good health for four years.
He then had epileptic paroxysms,
which  at first occurred once in two
months, but gradually increased in
frequency.  After a much longer
interval than usual, a  few weeks
before  his death, the fits returned
after a fright, recurred with great
frequency,  and  were fatal.   He
was  then twelve years of age ; his
right side had continued  weak ;
and  at the time of his death, the
  On the surface of the brain, un-
der the left parietal  bone, there
was a tumor the size of an egg, si-
tuated between the  pia mater and
the arachnoid ; internally it was of
a white and somewhat gelatinous
appearance, but  very firm,  and
when cut into, some serous fluid
was discharged from  it; no effu-
sion.—Communicated   by   Dr.
Beilby. 
       CASES  OF  ORGANIC  DIJ

          Symptoms.
right  lower  extremity was three
inches shorter than the other;—
his intellect had been weak, so
that he never could be taught to
read.

  Case XXVIII.—A man aged
40, the guard  of a coach, was
thrown from his seat behind the
coach, and received an injury of
his head, by which he was confin-
ed for  several weeks.  After his
recovery he became epileptic. The
fits generally occurred once in five
or six weeks.  After two years he
fell from his seat behind the coach
in one of the fits, and received va-
rious injuries, of which he  died in
a few days.

  Case XXIX.—A child aged 20
months—No symptom  remarked
had a constant motion of the head
from right to left—was pale  but
without fever, and did not  seem to
suffer. Died ematiated.

   Case XXX.—A  woman aged
50—Epileptic for  thirty  years;
but cough  which  excited acute
pain under the upper part of the
occipital bone.  In one of  the epi-
leptic fits  she received a  violent
blow on this spot, followed  by con-
stant  pain, and after six weeks, a
pulsatory tumor  appeared  on the
spot, which  could be pressed back
into the cavity of the cranium, and
this produced coma. After several
months, she  had palsy of the right
arm,  and both lower extremities,
and soon after died.

   Case XXXI.—A woman of 43
—Headach ; spasmodic affections
of the limbs. After seven months
was confined to bed—violent pa-
roxysms  of  headach, with loss of
memory, and frequent convulsive
attacks, which at last occurred se-
veral  times a day.   Died  sudden-
EASES  OF THE  BRAIN.    373

     Morbid Appearances.
  There was  thickening  of the
dura mater in several places.  At-
tached to the inner surface of the
thickened portions, there were se-
veral nodules of bone, the size of
peas, and very irregular on  the
surface.—Communicated by Dr.
Hunter.
  In right lobe  of cerebellum a
round firm cyst, the size of a hazel-
nut,  containing  numerous small,
hard concretions like  pieces  of
bone.—Andral.
  The tumor was generated in the
substance  of the dura mater.  It
projected inwards into a hollow on
the left hemisphere, and outwards
through an  opening in the bone
which measured two inches by
one and a half.  The dura mater
near it was remarkably vascular.-
Marigues, Mem. de Chir. p. 26.
  Four ounces of fluid in the ven-
tricles.  A tubercle the size of  a
nut in the left lobe of the  cerebel-
lum ;  surrounding substance much
softened.—Rochoux sur I'Apop. 
I
 374            SUPPLEMENT TO PART III.

          Symptoms.               Morbid. Appearances.
 ly in one  of them, six or  seven
 weeks after  she was  confined to
 bed.

   It is  unnecessary to  detail particularly the cases of this
 class.  They present the usual symptoms of the epileptic pa-
 roxysm, occurring  at  various  intervals, and  in  various de-
 grees of severity ; sometimes accompanied by violent attacks
 of headach, and sometimes with little uneasiness in the head.
 They are sometimes fatal suddenly in one of  the fits, some-
 times by  coma.   A  variety of morbid appearances have been
 observed  in such cases.  Portal 'observed a remarkable indu-
 ration of the pons Varolii; and  Sandifort found three tuber-
 cles in the dura mater near the sagittal  suture, on the right
 side, and in the anterior part  of the right hemisphere, a se-
 baceous tumor, the size of- a walnut.  In a case by Lieutaud,
 there were seven sarcomatous tumors near the longitudinal si-
 nus  ; and in another, a glandular tumor the size of a bean, in
 the substance of the right corpus striatum.  In a young man,
 mentioned by M. Poupart,  in  whom the fits occurred once a
 week, there was  a  thick white  substance, firmer than jelly,
 under the dura mater.  In a man, mentioned by Lamotte, who  •
 died of an abscess of the lungs, after having been many years
 epileptic,  several sharp bony spiculae were found between the
 dura mater and  the  pia  mater; their points  being directed
 against the pia mater.  Several cases of  the  same kind are
 referred to by Van Swieten, in one of which there was an ir-
 regular piece of bone in  the substance of the  cerebellum, an
 inch  long and half an inch broad.   In a case by Dr.  Ander-
 son of Leith, in which epilepsy came on after  a severe injury
 on the back of the head, the posterior part of the brain was
 found inflamed, and  much  hardened, with thickening of the
 membranes. A modification of epilepsy is met  with, in which
 the convulsion is confined to one side of the body.  In a case
 of this kind by Dr.  Anderson, a portion of the brain on the
 opposite side was much  indurated,  with adhesion and thick-
 ening of the membranes.   The same peculiarity in the symp-
 toms occurred in Dr. Beilby's case, mentioned in this section.
 In a  man, mentioned by  Lieutaud, the course  of symptoms
 was somewhat different from those epileptic affections.   He
 had violent headach for three  months, then violent convul-
 sions, which were rapidly fatal.   The longitudinal sinus, ex-
ternally and internally, was  covered with innumerable smaller 
CASES OF ORGANIC  DISEASES OF THE BRAIN.   375
glandular grains, and similar bodies were found on the choroid
plexus.  In the fourth  ventricle there  appeared a tumor the
size of an egg, formed by a congeries of innumerable glandu-
lar bodies, verging to suppuration.   Nearly the whole of the
cerebellum had the same appearance.
SECTION V.
Fifth Class.—Symptoms in the head, with paralysis.

                  § i.—hemiplegia.
          Symptoms.
  CaseXXXIL—A woman of 77
—violent convulsions  of the left
arm, which returned every two or
three  days for  ten  weeks,  with
weakness of the arm, then weak-
ness of the  leg, and  gradually
complete hemiplegia, the convul-
siou then ceasing—speech  then
lost, but mind entire—death after
eleven months without any  other
symptom.

  Case XXXIII.—A boy aged 11
—Sudden attack of dimness of
sight amounting to blindness.  It
went  off in a few  minutes, but
from that time his sight was gra-
dually impaired, and after a year
was nearly lost.  He then had an
affection resembling chorea; and
after a short time, suffered an  at-
tack in which he lay speechless
for  three days.  This was follow-
ed by hemiplegia of the right side.
He  complained much of his  head,
which appeared  to  his friends to
enlarge;  and he sometimes lost
his  speech for two or three  days.
His intellect was not affected, but
at times was extremely acute.  He
died after coma of five weeks con-
     Morbid Appearances.
  A hard, yellow, cancerous mass,
larger than a duck's egg, and com-
posed of many lobes in the sub-
stances of the right hemisphere.—
Rostan (Ramollissement de Cer-
On the surface of the left hemi-
sphere,  the  membranes  adhered
firmly to the surface of the brain
in the  middle  lobe—on  raising
them at this place, fluid escaped in
great quantity, which was found
to have been discharged from the
cyst of an immense hydatid con-
tained within the left  lateral ven-
tricle, and which had nearly ad-
vanced to the circumference of the
brain.  It contained about sixteen
ounces of limpid fluid, and besides
this, there were several ounces in
the proper cavity of the ventricle.
—Communicated by Mr. Head-
ington of London. 
376
SUPPLEMENT TO  PART III.
           Symptoms.
tinuance,  about  a  year  after the
attack of hemiplegia, and two years
after  the  commencement  of the
disease.

  Case XXXIV.—A man of 63
—after a blow on the head, head-
ach and  sense of  weight in the
head, at first occurring  in parox-
ysms, then more permanent, with
slight weakness of the right  side,
and transient loss of recollection.
Symptoms gradually increased to
perfect  hemiplegia   of  the  right
side—loss  of speech—twisting of
the mouth  to the left,  and great
failure of intellect.  Died coma-
tose  after more  than two years.
The  coma continued a week.
  Case XXXV.—A boy  of  13
—headach—hemiplegia of the left
side for five  or six  weeks  before
death—loss of speech and memo-
ry—rigidity of the paralyzed limbs
—occasional pain in the affected
leg, and tremulous motion of both
arms—tetanic  symptoms.

  Case XXXVL—A man aged
36—occasional attacks of severe
headach, shooting from behind for-
wards.  After  a few months dou-
ble  vision—then  gradually  palsy
of the right  side,  with distortion
of  the  mouth and  inarticulate
speech; the left  eye drawn to-
wards  the  nose—pulse  natural.
About two months from the com-
mencement  of the  paralysis, he
became convulsed,  aud  died  in
twenty-four hours.

  Case XXXVII.—A girl aged 6J
—gradual  loss  of power  of right
arm and leg, with great rigidity—
Morbid Appearances.
   A reddish brown and firm  tu-
mor, the  size of an  egg, on the
outer and anterior part of the left
hemisphere;  it was full of blood,
which  seemed to be contained in
it in some places as it  is  in the
spleen ; in others it was in small
clots a line or more in  diameter,
and very firm.  The tumor adher-
ed slightly to the dura mater and
the arachnoid, which was red and
thickened where it covered the tu-
mor.   Below, it was imbedded in
the substance of the hemisphere,
and the cerebral matter was soft-
ened.  One ounce  of fluid  in the
ventricles.—Rochoux.

  A  tubercle the size of a large
egg, and five  or six smaller ones
in  the substance  of the right he-
misphere ; four in the left the size
of chestnuts—several of them sup-
purated—pus betwixt  the  arach-
noid and pia mater, and turbid flu-
id in the ventricles.—Bouillaud.

  A tumor the size of a hazelnut,
lying on the left side of the tuber
annulare,  and sunk into it.  It ex-
tended into the left corpus pyra-
midale, compressing  it  and the
abductor nerve, and was closely
attached  to  the  basilar  artery,
which  contained at this place a
small  coagulum,  and  its  coats
were very soft.  The  tumor was
in  a  state of  imperfect suppura-
tion.— Yelloly, Med. Chir. Trans.
I.,  181.

  Tuber annulare enlarged and lo-
bulated, and  changed into a gela-
tinous mass with white bands run- 
         CASES OF  ORGANIC DISEASES  OF THE  BRAIN.   377

            Symptoms.                Morbid Appearances.
  squinting—loss of articulation— ning through it.  Effusion m the
  difficult deglutition—palsy of left ventricles.—Bright.
  side of face.  Limbs  of left side
  afterwards affected, though in a
  milder degree  than the right—af-
  terwards  difficult   respiration-
  complete loss  of power of deglu-
  tition.   Death  in five months.

    The cases  of this  class present little  variety in  the symp-
  toms.   They are generally, headach with or without  affec-
  tions of the sight, and after some time weakness of one side,
  which gradually increases to perfect  paralysis.   In a case by
  Bonetus, and in another exactly  similar by Blancardus, there
  was a tumor three inches long attached  to  the side of the
  third sinus.   A gentleman,  mentioned  by Mr. Gooch, along
  with a  variety  of nervous  symptoms, had an  excruciating
  pain of one arm, beginning at the finger ends, and gradually
  ascending as  high as the insertion of the  deltoid.   The arm
  at last became paralytic, and  soon  after he  died  of  convul-
  sion.   Two small encysted tumors were found in the  surface
 of the brain on the opposite side  from the  affected  arm.  In
  a case by Bouillaud,  with partial  hemiplegia of the right side
 of long standing, with  much derangement of speech  and
 weakness of mind, there was a tumor the  size of an egg in
 the anterior lobe of the left hemisphere, and  another  smaller
 in the Siiddle  lobe.   They were internally  cellular, and con-
 tained blood mixed with a filamentous substance, and a mat-
 ter resembling concrete pus.

                       § II.—Paraplegia.

           Symptoms.                Morbid Appearances.
   Case XXXVIII.—A  man of 48    Left lobe of the cerebellum was
 -—acute headach for a year, follow- almost entirely  scirrhous, of a pale
 ed by paraplegia.  Five months flesh-colour, and seemed to be com-
 after died suddenly.              posed of numerous small corpus-
                               cles closely  compacted,  without
                               any interstices, or any  appearance
                               of  vessels.—Morgagni, Ep. 62.

  Case XXXIX.—A man of 35    On the  surface of the pons Va-
__fixed pain in the occiput extend-  rolii,  there  were two  triangular
ing down the  neck—occasional  fleshy  tumors  nearly  united  by
vertigo and sickness.  After five  their apices.  The base of the one
months hemiplegia of the left side  extended into the right crus cere-
48 
378
SUPPLEMENT  TO PART 111.
           Symptoms.               Morbid Appearances.
and impaired vision.  Hemiplegia  bri, that of the other into the me-
diminished  gradually,  and  after  dulla oblongata.  The disease pe-
five or  six months more, became  netrated into the substance of the
liable to fits of stupor, which were  pons.  There was much effusion
preceded by violent pain and ver-  under the arachnoid.—Edin. Jour.
tigo, and  occurred  occasionally  XI. 470.
twenty times in a day—blindness
of the  right eye—failure of  me-
mory—then paraplegia, and a fort-
night before his  death palsy of the
upper extremities also.—Duration
of the  complaint was a year and
eight months.

  Case XL.—A man  aged 63—    A tumor the size of a hen's egg
general and complete paralysis of  in the medullary substance of the
the whole body, which came on  left hemisphere, betwixt  the fis-
gradually and insensibly, without  sure of Sylvius and the part which
any evident cause—speech indis-  rests upon the tentorium.   It was
tinct—mind  entire  to  the  last,  contained in a cyst, and was in-
Died of gangrene of the nates.    ternally  of  a  brownish  colour
                               and lardy consistence.—Bui. Fac.
                               Med. May, 1816.

   I have already alluded to the uncertainty which attends
cases  of this  class,  from the  circumstance of there having
been in general no examination of the  spinal cord;  and  per-
haps it may still be considered as a point not  absolutely as-
certained, whether diseases in the  brain produce paraplegia
without any  affection of the cord.  If this  does  take place,
it will probably be in those cases in  which the disease is
about  the pons or medulla oblongata;  though  in  these cases
one should rather expect universal paralysis, such  as occurred
in Cases XXXIX. and XL., of this Supplement.   From the
observations recorded under the pathology of the spinal cord,
it will appear that disease may frequently exist both  in the
brain and in the  cord at the same time, and that this particu-
larly is true of tubercles.   In a case related by Dr. Hawkins,
in  the Medical and Physical  Journal  for  1826,  there  were
numerous scrofulous  tubercles,  both in the brain and cerebel-
lum of a man  of 23; the symptoms had been fits  resembling
epilepsy,  with  dyeuria, partial paraplegia, and impaired speech
and vision.  He  died after four months, having been coma-
tose for  three  or four days  before  death.   Had the spinal
cord been examined in this case, it is  very probable that tu-
bercular disease would have been met  with in it  also.   The 
CASES OF  ORGANIC  DISEASES OF THE BRAIN.   379
same observation applies to  a case  by  Bouillaud, in which
there was paraplegia  with loss of  speech  and  intellect, in
connexion with a tubercular mass, the size of a turkey's egg,
in the anterior part of the right hemisphere.  A girl aged 14,
mentioned by Lallemand, had hemiplegia  of the right side,
of which she recovered;  four months after she had  paraple-
gia with loss of feeling, which  extended over the  abdomen
and the thorax;  she died in  sixteen days.   There  was re-
markable induration of a small part  of  the  left lobe  of the
brain, on  the outside  of the  ventricle, and in the vertebral
canal there was extensive extravasation of blood with ramol-
lissement of  the cord at the seventh cervical vertebra.
SECTION VI.
Sixth Class.—Prominent symptoms in the digestive organs.
           Symptoms.
   Case XLI.—A medical man in
 the meridian of life, had been for
 a year liable to attacks of dyspep-
 sia,  with  headach.   In  October,
 1815, he had severe headach with
 fever, relieved  by  bloodletting;
 then complete want of digestion,
 headach, general emaciation, and
 frequent vomiting, which occurred
 chiefly in the morning.  He had
 various uneasy feelings, which he
 referred to his liver, and his com-
 plaints  were  ascribed  to  this
 source by the most eminent prac-
 titioners whom he consulted.  In
 August, 1816, he had severe head-
ach^ and nothing agreed  with  his
 stomach; almost every thing  be-
ing vomited.  After some time the
pam was relieved, but the. morn-
ing sickness and vomiting conti-
nued, with increasing emaciation,
torpid  bowels,  frequent eructa-
tions^and hiccup.  In the end of
September had twice a slight con-
vulsion.  Headach then periodica}
      Morbid Appearances.
  Four ounces of fluid in the ven-
tricles.  On the inferior part of the
left lobe of the cerebellum, there
was an encysted tumor, the size of
a French walnut, besides a vesi-
cular  portion  connected  with it,
containing  some yellow serum.
The tumor was invested both by
the dura mater and pia mater, and
was attached by a small pedicle to
the substance  of the cerebellum,
where it had formed a depression
in which it  was imbedded.  On
the corresponding part of the op-
posite lobe there was a small flo-
rid  tumor,  the size  of a large
pea. The abdominal viscera Avere
sound.—Med  Repos. vol. vii. 
380
SUPPLEMENI TO  PART III.
          Symptoms.                Morbid Appearances
—mind entire,  but  conversation
induced headach, and sometimes
convulsion.  October 9, died sud-
denly in convulsion.

  Case XLII.—An  officer aged    The dura mater covering the ce-
27—constant nausea and frequent  rebellum at its posterior and infe-
vomiting—slight thickening of the  rior part was  thickened and carti-
pericranium—headach and gene-  laginous,  and the  diseased state
ral indisposition.  After a consi-  had extended considerably into the
derable  time, numbness of  the  substance of the cerebellum, where
right side.   Five weeks after this,  it lay in contact with it.  Other
he died suddenly in the night.     parts of the cerebellum softened.
                              membranes of the spinal cord hard
                              and thickened.  Thoracic and ab-
                              dominal viscera sound.—Med. Re-
                              pos., vol. viii.

   Many other cases are on record, in which the  only morbid
appearances were in the head,  though some of the most pro-
minent symptoms had been in  the stomach.  Some of  these
resemble what has  been called  sick headach, while others  are
chiefly distinguished  by  remarkable disturbance  of the  di-
gestive functions.   There is generally more or less headach,
with various uneasy feelings in  the head; but  these symp-
toms are  sometimes not urgent, so  that many  of the  cases
have, through  a great part  of their progress, been  referred
to the  digestive organs, the  symptoms in the head being
considered as symptomatic.  A boy aged  14, mentioned by
Mangetus, had loss  of  appetite, obfuse  headach,  debility
and  emaciation; then vomiting, with  more acute headach,
and  he died after various intermissions.  Three tumors were
found in the brain, one in the situation of the corpora quadri-
gemina, and two others the size of walnuts in the substance
of the brain.   A young man,  mentioned in the  Medical Ob-
servations and  Inquiries, vol.  vi., had  various  complaints in
the head and bowels,  which were ascribed to worms.  After
some time he  had attacks of stupor  and  forgetfulness, and
died delirious.   The only morbid appearance was ossification
of no great extent  in the dura  mater, with appearances of in-
flammation in the adjoining membranes.  Similar ossification
in the falx was  found by Dr. Lettsom, as the only morbid ap-
pearance in a gentleman who had been  long affected with a
train of obscure complaints, the most  urgent of which were
obtuse headach with  frequent  vomiting.   (Mem.  Med. Soc. 
CASES OF ORGANIC  DISEASES  OF THE  BRAIN.    381
of London, vol. iii.)   On the other hand, it is to be kept  in
mind that similar ossifications have been met with in cases in
which there existed no symptoms  that  could  be ascribed  to
them.    This  part of  the subject, therefore, is involved  in
much obscurity.
                       SECTION VII.

Seventh Class.—Vertigo and  apoplectic symptoms.—Slight and
                 transient apoplectic attacks.
          Symptoms.
  Case XLIII.—A man aged 73
—headach with occasional attacks
of giddiness, and loss of recollec-
tion.  He did not generally fall
down,  but sometimes  continued
walking, without knowing whither
he was going; at other times the
attack resembled intoxication ; his
gait  was feeble *nd tottering, and
the attacks gradually increased  in
frequency and violence, though he
generally  recovered his recollec-
tion in a very  short time ; but at
length, after six months, a more
severe attack occurred, frftm which
he did not recover; he was now
confined to bed with severe head-
ach,  giddiness, loss of memory,
and  incoherence; and about the
twelfth day had severe pain and
partial  palsy of  the left leg and
arm.  He had  then general con-
vulsion, followed by perfectTiemi-
plegia  and coma, and died about
the 23d day of his confinement.

  Case XLIV.—A  man aged 36
—after a wound in the head, which
healed  readily, had constant head-
ach for five years and a half; then
fits of  stupor,  which came on  at
uncertain  intervals,   sometimes
twice a week, sometimes once a
fortnight.  They generally lasted
     Morbid Appearances.
  Three  ounces of fluid in the
ventricles, cerebral substance very
firm.  In the posterior lobe of the
right hemisphere, there was a firm
tumor  the  size  of a small  pi
geon's  egg; internally of a pale
flesh-colour, and granular texture.
It was not enclosed  in a capsule ;
but for a considerable  part of its
circumference, was covered by a
texture  resembling  the  fibrous
bands of carcinoma.  The tumor
communicated with the  ventricle
so as to form part of the wall  of
the posterior and inferior cornua,
and the margin of the pes hippo-
campi was attached to it.   The pia
mater lining the ventricle at this
place  was  very  vascular.—Com-
municated by  Dr. Hunter.
  A  scrofulous tumor, larger than
a hen's egg, in the  middle of the
left hemisphere of the  brain, ex-
tending in depth to nearly on a
line with the corpus callosum.   It
seemed to be merely a part of the
brain in  an indurated  state.   A
piece of bone, the size of the fin- 
382
SUPPLEMENT TO PART III.
           Symptoms.                   Morbid Appearance.
 about an hour and a half, and  he ger-nail, was attached to the left
 had warning of their approach so side  of  the longitudinal  sinus.
 as to lay himself down.  In  the The veins  on the loft hemisphere
 intervals all  the functions  were were more  distended with blood
 natural.  After  seven or  eight than  those  on the right.—Med.
 months,  the  paroxysms  became Chir. Trans. IV.,  188.
 more frequent, and he  died  sud-
 denly in one of them.

   Case XLV.—A woman aged   A remarkable tumor under the
 28—severe headach, constant ver- base of the brain on the left side,
 tigo, nausea, occasional vomiting, resting on the petrous portion of
 frequent rigors, pain and deafness the temporal bone.  It consisted
 of the  left  ear, and the left eye of three portions; the anterior was
 somewhat affected.   After several the size of an egg, of a pink co-
 months  the  headach   increased, lour, and composed  of a spongy
 with occasional paroxysms of co- vascular  substance, like the tex-
 ma,  and  she died  at  last rather ture of the placenta, interspersed
 suddenly, having been for a day with small  cysts, containing a pu-
 ortwo affected with extensive ery- riform fluid ;  the posterior portion
 sipelas  of the head  and face.       was half the size  of the former,
                                 and of similar structure, but firm-
                                 er;  the middle portion was  the
                                 size  of a walnut  of a white co-
                                 lour, and of nearly cartilaginous
                                 structure.   The petrous portion of
                                 the  bone on which  the tumor rest-
                                 ed was absorbed  to the  depth of
                                 half an inch.—Author's Notes.

   Case XLVI.—-A  lady aged 64    Two small aneurisms, each a-
 __attacks of  headach;  giddiness  bout five-eighths of an inch in di-
 and imperfect vision, occurring at  ameter, formed by dilatation of the
 uncertain intervals ;  afterwards  internal carotid arteries, by the side
 mania;  at  last, after  five years,  of the cella Turcica, and contain-
 death with fever and delirium.     ing laminae of coagulated blood.—
                                 Trans, of a  Soc,  II., 193.

   Case XLVII.—A woman  aged    Extravasation of blood and ra-
 65—palsy of the right leg of long  mftllissement.   The anterior part
 standing ; lancinating pains of the  of the left hemisphere was  very
 head  occurring at  intervals;  at-  much hardened, and  of a reddish
 tacks of insensibility; death from  colour.  In  the substance of the
 gradual coma  after  an  apoplectic  right hemisphere there was an oval
 attack.                           tumor of a  reddish colour, partly
                                 hard and partly  softened.—Ros-
                                 tan.

   I have formerly described a very important  case referable
 to this class, connected with a remarkable  tumor formed by
a  deposition of new matter  betwixt  the lamina?  of the dura 
      CASES OF  ORGANIC  DISEASES  OF THE RRAIN.   383

mater,—(see Case VI., page 44,) and there are many others
on record exhibiting some  varieties of  the symptoms.   In
some  we find constant uneasiness, with vertigo; in others,
transient apoplectic attacks, while the  patient in the intervals
enjoys tolerable healthi   In other cases again, there is a con-
stant complaint of slight and  habitual giddiness, commonly
called weakness of the head, often accompanied by unsteadi-
ness of the  limbs.  In a case of the first kind, by Zeder, he
found numerous hydatids in the brain,  one particularly, in the
passage to the aqueduct of Silvius, and  containing within it
three smaller hydatids.   The  case which I have just referred
to (Case VI.) affords a remarkable example of the other class
of cases distinguished by transient apoplectic attacks; and  I
have quoted from Lancisi the case of  a  gentleman  who  had
apoplectic attacks, connected with thickening of the mem-
branes, and  a polypus tumor under  the  frontal bone.    A
gentleman, mentioned by Gooch,  had been for several years
liable  to attacks  in  which there  was sometimes a  shaking
of the head, and a kind  of emprosthotonos;  at other times
he became vertiginous, and fell down, deprived of sense for
a short time.  He was never  entirely  free from headach, and
brisk exercise excited giddiness, which went off immediately
upon resting.  He died suddenly in convulsion, and there were
found several osseous points arising from  the right parietal
and occipital bones, and irritating the  dura mater, which was
inflamed, and beginning  to  mortify.—(Gooch's  Appendix,

P\23H            *
  To  this  class also  Belong the cases in  which,  connected
with organic disease of the brain, there has occurred a gra-
dual loss of  the mental faculties, with  little complaint of pain,
or any urgent symptom.  In  a case of this kind, which ter-
minated in perfect stupidity or lethargy, Platerus found a firm,
fleshy-looking tumor, the size of a moderate apple, above the
corpus callosum.   In a similar case, by  Bouillaud, there was
a steatomatous encysted tumor in the  right hemisphere.
FINIS. 
 
 
 
 
 
 
NLM032068034