... - •■'■■ ■ (<^i\- < '0* r si Surgeon General's Office jCxja(rQoaog.crQiOQCQiQGao(3-QOQx^ i ^ G '( it/**- / / PATHOLOGICAL AND PRACTICAL RESEARCHES ON DISEASES OF THE BRAIN AND THE SPINAL CORD. BY JOHN ^ABERCROMBIE, M. D. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH, &C. AND FIRST PHYSICIAN TO HIS MAJESTY IN SCOTLAND. A NEW EDITION, ENLARGED BY THE AUTHOR. PHILADELPHIA: LEA AND BLANCHARD. 1843. MERRIAM AND COOKE, PRINTERS, WEST BROOK.FIELD, MASS. PREFACE. It is a matter of the utmost delicacy for a physician to obtrude 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 veracity 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 observa- tions on which his conclusions are founded. Hence arises the hes- itation 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 at- tach to a simple record of facts, in a concise and accessible form, apart both from hypothesis and system. The author of such a record contributes that which has a fixed and certain value, depend- ent only upon his correctness in distinctly describing what he has seen; and thus is furnished a series of facts which every practition- er may study for himself, and from which he may acquire a know- ledge 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 opitiion, in regard to the mode of conducting medical investigations. TLere appears to have been a tacit but very general admission of the fallacy of medical hypothesis, and the precarious nature of general principles in medicine; and there seems to be an increasing conviction of the indispensable necessity, of founding all our conclusions in medical science, upon an extensive and accurate acquaintance with the pa- thology of disease. The facts which are required for this purpose IV PREFACE. can be derived only from the contributions of practical men; and and it is of the utmost consequence that such persons should exten- sively record 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 individuals of a particular class; and it is only when they are deduced from a cor- rect examination of all these individuals, that they can possess either truth or utility. When they have been framed from a lim- ited observation, they are, m general science, useless, and in medi- cine, dangerous; and in regard to medical science we may perhaps venture to assert, that the purposes of practical utility are promot- ed 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 following treatise has, from time to time, submitted to the profession a series of researches, on various important subjects, of a pathological and practical nature; and he now intrudes upon their attention with far- ther observations, in a more connected and more extended form. In doing so, he has no system 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 been 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 Organic. This ar- rangement will probably answer every practical 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 PREFACE. V often distinguished by apoprectic 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 pres- ent state of our knowledge in regard to the pathology of Nerves. PREFACE TO THE THIRD EDITION. In the third Edition, a considerable number of new facts and ob- servations have been added from various sources. The more im- portant of the new matter, of an original kind, will be found in cases 7, 26, 80, 85, 96, 121, and 132. In preparing this Edi- tion, the Author has also availed himself of many important obser- vations, 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. CONTENTS. PART I. Page OF THE INFLAMMATORY AFFECTIONS OF THE BRAIN.......17 SECTION I. GENERAL VIEW OF THE SYMPTOMS INDICATING INFLAMMA- TORY DISEASE WITHIN THE HEAD . . . . 18 SECTION II. OF THE PRINCIPAL SEATS AND TERMINATIONS OF THE DIS- EASE. . . .....27 Seats . • ■ . >b. 1. Dura Mater. 2. Pia Mater and Arachnoid. 3. Substance of the Hemispheres. 4. Dense Central Parts—Fornix, Septum, &c. Terminations .... ... 28 1. Fatal in the Inflammatory Stage. 2. Serous Effusion. 3. Deposition of False Membrane. 4. Suppuration. 5. Ramollissement, or Softening of the Cerebral Substance. 6. Thickening of the Membranes, &c. SECTION III. INFLAMMATION OF THE DURA MATER ... 33 Idiopathic ib' Connected with Disease of the Ear and Caries of the Temporal Bone with Disease of the Nose . • • with Caries of the Bones of the Cranium with Obliteration of the Lateral Sinus . Chronic, with remarkable Thickening . • • • B 41 42 44 45 X CONTENTS. SECTION IV. Page INFLAMMATION OF THE ARACHNOID AND PI A MATER, OR MENINGITIS . . . - 43 § 1. Simple Meningitis in the most common Form ... 49 § 2. Meningitis of very great Extent, with Obscure Sypmtoms . 51 § 3. Meningitis of very small Extent, with Severe Symptoms . . 52 § 4. Meningitis of the Base . . ... . 53 § 5. Meningitis with Suppuration on the Surface . . ib. § 6- Meningitis with Suppuration in the Ventricles ... 54 § 7. Meningitis of the Cerebellum . . ... . 55 § 8. Of a very dangerous Modification of the disease which shows only increas- ed Vascularity . . •, . . . 56 SECTION V. INFLAMMATION OF THE SUBSTANCE OF THE HEMISPHERES 63 § 1. Fatal .in the Inflammatory Stage . - ■■..-.'■ 64 § 2. The Affection in a Chronic form . . . 67 § 3. The Inflamed Mass passing into Ramollissement ... 70 § 4. Extensive Ramollissement of the Corpus Striatum ... 72 § 5. The Affection in a Chronic form, with Ramollissement of Small extent, and Remarkable symptoms . . ' . . 73 I 6- The Affection in a Chronic form, with extensive Ramollissement and Re- markable Disease of the Basilar Artery . . . 75 § 7. Ramollissement combined with SuppuratiDn ... 76 § 8. Undefined Suppuration ...... 77 § 9. Extensive Undefined Suppuration with Extravasated Blood . . 79 § 10. The Encysted Abscess . . . . . ib. § 11. Abscess of the Corpus Striatum of very small Extent . . 84 § 12. Abscess of the Medulla Oblongata ..... ib. § 13. Abscess of the Cerebellum ...... 85 I 14. Ulceration of the Surface of the Brain .... 86 General Review of the Subject ■ ... 87 SECTION VI. INFLAMMATION OF THE CENTRAL PARTS-CORPUS CALLOSUM, FORNIX, SEPTUM LUCIDUM, AND THE MEMBRANE LINING THE VENTRICLES . . ... 9S $ 1. Inflammation of the Membrane lining the Ventricles . 100 5 2. The Inflammatory Origin of the Ramollissement of the Septum Lucidum 101 CONTENTS. X) Paga § 3. Ramollissement of the Central Parts, Fatal without Effusion. . 101 § 4. Ramollissement of the Central Parts, combined with Serous Effusion, constituting the most common form of Acute Hydrocephalus . 103 Cases illustrating some important Varieties in the Symptoms . 105 The Affection occurring in Phthisical Cases . • - 108 5 5. Cases of Simple Effusion , . . .110 General Review of the Subject . 112 SECTION VII. CAUSES OF THE INFLAMMATORY AFFECTIONS OF THE BRAIN 114 1. Febrile Diseases ..... 2. Injuries . ..... 3. Suppressed Evacuations 4. Appearing in Connection with other Chronic Diseases . fi. Passions—Stimulating Liquors—Heat of the Sun, &c. . Hi ib. Ill ne 117 SECTION VIII. TREATMENT OF THE INFLAMMATORY AFFECTIONS . . Ill Examples of Successful Cases under various Forms . - 118 APPENDIX TO PART I. SECTION I. OF TUBERCULAR DISEASE OF THE BRAIN _ , . . 12i SECTION II. OF CERTAIN AFFECTIONS OF THE BONES OF THE CRANIUM 187 SECTION III. OF CERTAIN AFFECTIONS OF THE PERICRANIUM * 1*5 Xll CONTENTS. PART II. OF THE APOPLECTIC AFFECTIONS. Page General View of the Subject . • lft2 General View of the Symptoms, referred to Three Classes . 153 SECTION I. OF THE CASES OF THE FIRST CLASS, OR THOSE PRIMARILY AP- OPLECTIC . . . . . 154 § 1. Apoplexy without any Morbid Appearance, or Simple Apoplexy . 155 § 2. Apoplexy with Serous Effusion . . . . . 158 Extensive Effusion without any Apoplectic Symptoms- . 160 Of the term, Serous Apoplexy ..... 162 Conclusion from a Review of this part of the Subject . ib. SECTfON II. OF THE CASES OF THE SECOND CLASS, OR THOSE WHICH BE- GIN WITH A VIOLENT ATTACK OF HEADACHE AND PASS INTO APOPLEXY GRADUALLY, . . . .163 § 1. The Coma rapidly Supervening on the First Attack . . 165 § 2. An interval of perfect recollection for several hours, betwixt the Attack and the Occurrence of Coma ..... 166 § 3. An interval of three days betweeu 'the Attack and the Occurrence of Coma ........ 168 § 4. The fatal Coma occurring a fortnight after the first Attack ib- § 5. Two distinct Extravasations . . . . 169 § 6. The Extravasation confined to the Third and Fourth Ventricles, with re- markable Disease of the Arteries of the Brain . . . 171 § 7. Extravasation on the Surface of the Brain ib. § 8. Extravasation in the Cerebellum ..... 174 § 9. Extravasation in the Substance of the Tuber Annulare . . ib. § 10. Extravasation in all the Ventricles, and along the whole course of the Spi- nal Cord ....... ifQ § 11. Extravasation, in a Cyst, formed by separation of the lamina? of the dura mater, from rupture of the middle Meningeal Artery . 177 Review of the Subject, and of the various Sources of the Haemorrhage jn Cases of this Class Of Disease of the Arteries of the Brain Similar Disease of the Veins ib. 178 180 CONTENTS. X1U SECTION III. OF THE CASES OF THE THIRD CLASS, OR THE PARALYTIC CASES........182 § 1. Paralysis with Serous Effusion, or with slight Morbid Appearances 183 § 2. Paralysis with Extravasation of Blood of small extent . 186 Progress of these Cases—Formation of a Cyst—and Absorption of the Coagulum . . :. . . . 188 A. The Cyst empty—the Patient dying of another Disease 189 B. The Cyst empty—the Patient dying of a fresh Attack 192 C. Two Cysts empty—the Coagulum partly absorbed from a Third—the Patient dying of a fresh Attack ! . 193 194 197 200 201 D. The Cyst on the Surface . \ § 3. Paralysis with Ramollissement . ''.' . § 4. Paralysis with Inflammation and its Consequences General Observations on Paralysis General Pathology of Paralysis "-. t . . . . . 205 SECTION IV.- OUTLINE OF THE TREATMENT OF APOPLEXY 209 APPENDIX TO PART II, CONJECTURES IN REGARD TO THE CIRCULATION IN THE BRAIN........217 PART III OF THE ORGANIC DISEASES OF THE BRAIN 227 1. Tumors formed by Thickening of the Membranes, &c. 227 2. Deposition of Albuminous matter .... 227 XIV CONTENTS. 3. Dense White Tumor, apparently not Organised 4. Flesh-colored Organised Tumor 5. Tubercular Disease .... 6. Induration of the Cerebral Substance . 7. Ossifications ..... 8. Hydatids . . Page 227 228 ib. ib. ib. 229 OUTLINE OF THE SYMPTOMS REFERRED TO SEVEN CLASSES 1. Headache, without any other remarkable Symptoms . 2. Headache, with Affections of the Senses 3. Headache, Affections of the Senses, Convulsion 4. Convulsion, without affections of the Senses . 5. Cases with Paralysis . . . 6. The Prominent Symptoms in the Stomach 7. Cases with Slight and Transient Apoplectic Affections 230 231 ib. 232 ib. 233 ib. Tart iv. OF THE DISEASES OF THE SPINAL CORD AND ITS MEMBRANES 237 SECTION I. MENINGITIS OF THE CHORD 238 SECTION II. INFLAMMATION OF THE SUBSTANCE OF THE CORD 244 § 1. Fatal in the Inflammatory stage 244 § 2. Ramollissement of the Cord 245 § 3- Undefined Suppuration .... 255 § 4. Abscess ... 256 CONTENTS. XT SECTION III. Page SEROUS EFFUSION IN THE SPINAL CANAL .257 SECTION IV. SPINAL APOPLEXY.......259 SECTION V. THICKENING AND FUNGOID DISEASE OF THE MEMBRANES, AND FUNGUS OF THE CORD ITSELF .262 SECTION VI. INDURATION OF THE SPINAL CORD .... 264 SECTION VII. NEW FORMATIONS COMPRESSING THE SPINAL CORD 266 SECTION VIII. DESTRUCTION OF A PORTION OF THE SPINAL CORD 267 SECTION IX. CONCUSSION OF THE SPINAL CORD ... 263 SECTION X. OF CERTAIN AFFECTIONS OF THE BONES OF THE SPINE . 278 SECTION XI. CONCLUDING OBSERVATIONS ON THE PATHOLOGY OF THE SPINAL CORD, WITH REFERENCE TO VARIOUS ANOMALOUS AFFECTIONS 280 XVI CONTENTS. APPENDIX TO PART IV. Page OUTLINE OF THE DISEASES OF NERVES .297 SELECTION OF CASES ILLUSTRATIVE OF THE ORGANIC DIS- EASES OF THE BRAIN, BEING A SUPPLEMENT TO PART III. 309 D 1 S K A S E S OF THE BRAIN, &c PART I. OF THE INFLAMMATORY AFFECTIONS OF THE BRAIN. Peculiar difficulties attend the investigation of inflammatory affec- tions of the brain. In the inflammatory diseases of other organs, we ire 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 dis- ease 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-establish- ed 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 exam- ination after death, in a great proportion of the cases referred to, has on this principle been considered as explaning the symptoms, and here probably the investigation has 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 accute hydrocephalus. More extensive acquaintance with the phenomana of this class of diseases has shewn 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 concomitant 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 3 18 INFLAMMATORY affections. 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 exist 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 mem- branes, 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 commonly called acute hydrocephalus, the im- portance of this investigation is particulary 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 disease, ter- minating by effusion; that many of the leading symptoms are not con- nected with the effusion, but with the inflammatory condition which goes before it; and that without any effusion it may be fatal, with all the symptoms which have usually been considered as characteristic of hydrocephalus. When we enter more particularly upon this inquiry, we find inflamma- tory disease in the brain varying considerably in its characters in dif- ferent cases. These varieties appear to be referable to three circum- stances;—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 Arachnoid, the substance of the Hemispheres, of the deep-seated central parts of the brain. In its activity, it varies from the highest degree of active inflammation, to the chronic or scro- fulous inflammation with the lowest degree of activity, and with nume- ous 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 ramollisse- ment of the cerebral substance. The phenomena resulting from these 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 indi- cate 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 inflammation of the SYMPTOMS. 19 substance of the brain, as distinguished from inflammation of its'mem- branes; but the distinction is not of much practical importance, and our present purpose will be answered by a general view of the symp- toms which indicate inflammation of any of the parts within the cran- ium. 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 modifications, 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 Phremitis of systematic writers. It is characterized by fever, watch- fulness, acute headache, 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 occasionally in fever, and in mania; and a condition nearly allied to it sometimes occurs after injuries of the head. Circumstances will be afterwards mentioned, which render it probable that in this form of the disease the inflammation is primarily seated in the membranes of the brian. 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 disease; for the cases which are referable to this class, when they terminate fa- tally, are generally rapid in their progress, and the appearances on dis- section are often unsatisfactory. There is an affection of frequent occurrence, which perhaps may be referred to this head. It is char- acterized by a peculiar 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 consequently to be considered as not being attended with danger. But it is an affection of great danger, and is often very rapidly 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 at- tention, the first symptom that excites alarm is a sudden attack of convulsion. This in some cases occurs without any previous illness; in others it is preceded by slight complaints which had attracted little attention;—in one case which will be described, it was preceded by vomiting, in another, by slight headache for several days. The con- vulsion is generally long and severe; in some cases it is followed im- mediately by coma, which in a few days is fatal; in others, the con- 20 INFLAMMATORY AFFECTIONS. vulsion recurs frequently at short intervals, the patient in the intervals being sensible and complaining of headache, 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 com plete recovery from it; and for several days the patient appears to be in the most favorable state, when, without any warning, the con- vulsion returns, and terminates 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 pa- ralysis of the part affected; and in some cases, the first symptom is a sudden attack of paralysis without the preceding convulsion. These cases are remarkable from their resemblance to the ordinary attack ol hemiplegia. It will appear in the sequel, that they are often con- nected with inflammation of a small defined part of the cerebral sub- stance; 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 ramol- lissement or peculiar softening of the cerebral substance, to be after- wards 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 chil- dren, but may also appear in adults. It is usually preceded for a day or two by languor and peevishness: these are followed by an ac- cession of fever, which is sometimes ushered in by severe shivering. The patient is oppressed and unwilling 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 extends along the neck; and sometimes pain is complained of in the arms and in other parts of the body. The pupil is usually 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 vio- lent grinding of the teeth. The bowels are generally obstinate, but frequently 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 awaking 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 delirium, there occurs a peculiar forgetfulness, the patient using one word instead of another, misnaming persons and SYMPTOMS. 21 things, mistaking the day, or the time of the day, or showing in some similar manner a confusion of thought, which has no resemblance to the delirium of fever. Sometimes he is sensible of it, and appears anxious to correct the mistakes which he has made. These symp- toms 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, becom- ing 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 counted as high as two hundred in a minute. It is through the whole course of the disease extremely un- equal 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 aflect'ous 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 a flections; and, after he has continued in this state for a few days, the disease is fatal. The duration of the complaint is extremely various; it is in some cases drawn 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 generally a remarkable remission of all the symptoms, giving san- guine 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. Tn some cases the pulse does not become slow, but continues through the whole course of the disease of nearly uniform frequency.—In young children who cannot describe their feelings, this form of the disease is charac- terized by fever, flushing, restlessness, and screaming, often with vom- iting; these symptoms 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 oppression, 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, com- monly in young persons towards the age of puberty and up- wards. It begins like a slight feverish disorder, and for a considera- ble time excites no alarm. There is slight headache, with general uneasiness of the limbs, impaired appetite, and disturbed sleep; the tongue is foul, and the pulse slightly frequent, probably from 96 to 100. After a few days the complaint 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 becomes 22 INFLAMMATORY AFFECTIONS. clean, there is some appetite, and better sleep: but there is still some complaint of headache, 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 char- acter. It is not perhaps before the sixth or seventh day, that even an attentive observer begins to remark, that the degree of headache, though not severe, is greater and more permanent than corresponds with the general symptoms of fever; that the tongue is becoming clean, the pulse coming down, and the appetite improving, while the headache continues, with an unwillingness to be disturbed, and a de- gree of oppression which is not accounted for by the degree of fever. In this manner the disease 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 headache is increased, with an evident tendency to stupor. This instantly marks a head affection of the most dangerous character, and the patient now lies for several days in a state of considerable stupor, sometimes with convulsion, of- ten 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, but soon relapses into perfect coma, and dies in three or four days. The duration of the disease is uncertain; 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 excited 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 fol- lowed by coma, generally with squinting, and in a few days by death.— This form of the disease might have been considered as a modifica- tion of the former, as the symptoms differ only in degree; but I have thought it worthy of a separate description, on account of the insidi- ous 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 slight- est complaint of headache 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 headache 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 stand- ard, or below it, frequently about 60; the face is in some cases flush- ed, in others rather pale; in some cases the eye is natural, in others SYMPTOMS. 23 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 oppres- sion, 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 af- fected; 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 sensi- bly. This condition, when it is not accompanied by fever, is always characteristic of a dangerous affection of the brain. There is also frequently observed that peculiar 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. Some- times 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 in some cases continues three or four days, in others not above twelve hours; and sometimes the disease is fatal without perfect corna, the patient being able to answer questions dis- tinctly 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 description, all the va- rieties in the symptoms. One variety has been added by M. Gen- drin, which is worthy of attention. It comes on in a very insiduous manner, at first often without either headache or fever. There is chiefly observed a certain obscuration of the mental functions, ac- companied with lassitude and an appearance of mental depression. The patient seems scarcely to comprehend what is said to him,— asks the same questions several times in succession,—and answers questions put to him with slowness and hesitation. He complains of little unless a general feeling of being indisposed; and thus the symp- toms 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, becoming 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 appearances of amendment which of- ten take place in all the forms of'the disease. Even in those cases 21 INFLAMM \T0RY AFFECTIONS. which have assumed the most formidable aspect, every alarming symptom may subside. The pulse perhaps continues frequent, but it also is coming down; at our successive visits we find it falling regu- larly, and we are disposed to hope that a few days will bring the case to a favorable termination. During this deceitful interval, which may continue for several days, I have known a parent intimate to the medical attendant that his farther visits were unecessary, and I have known a physician take his leave, considering his patient as convales- cent. As the pulse falls, the patient is disposed to sleep; this per- haps is considered as favorable; it falls to the natural standard—he then sleeps almost constantly; and in another day this sleep termi- nates in coma. The pulse then begins to rise again; it rises to ex- treme frequency, and in a few days more the patient dies. All this may go on with very little complaint of headache, and without any symptom that will lead a superficial observer to suspect danger, until he finds his patient gliding into coma at the very time when he ex- pects recovery; for the period when the pulse falls to the natural standard is the time when the coma becomes evident, and the sit- uation of the patient probably hopeless. Whenever, therefore, at any period of a febrile disease, there have been remarkable symptoms in the head, such as violent headache, with vomiting and impatience of light, stupor, convulsive affections, or affections of the sight, —though these symptoms may have entirely subsided, and the com- plaint may again have assumed the characters 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 ob- server 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 peculiar 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 profession, that cases occur in which all these symptoms are wanting, 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 rapid- ly 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 primary and idiopathic affec- tions of the brain, or whether some of them ought to be looked upon as secondary or symptomatic. It is, however, an important fact, that this disorder does very often occur as a symptomatic affection SYMPTOMS. 25 in the course of other diseases; the most common of which are,—con- tinued fever,—scarlatina,—hooping cough,—measles, pneumonia,— phthisis, and diseases of the kidnies. It may be useful, therefore, 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 headache with throbbing and giddiness, es- pecially if the pain be referred to a particular spot, and al- ways to the same part,—tinnitus—sense of weight and ful- ness—stupor—a great propensity to sleep. In many ob- scure and insidious cases, a constant feeling of giddiness is the only remarkable symptom. In the Eye.—Impatience of light—unusual contraction or dilatation of the pupil—double vision—squinting—blindness—distor- tion of the eyes outwards—paralysis of the muscles of the eyelids, producing, according to the muscle that is affect- ed, either the shut eye, or the gaping eye—transient attacks of blindness or double vision—objects seen that do not ex- ist—a long-sighted person suddenly recovering 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 quick- ness of speech, or unusual slowness. In the Pulse.—Slowness and remarkable variations in frequency. In the Mind.—High delirium—transient fits of incoherence—pe- culiar confusion of thought, and forgetfulness on particular topics. In the Muscles.—Paralytic and convulsive affections—sometimes confined to one limb, or even 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 in a very small part of a limb,—and various morbid conditions of sensation. In the Urine.—There frequently occurs a remarkable diminution 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 acrimony, as the quantity diminishes. 4 26 INFLAMMATORY AFFECTIONS. In this important diagnosis, however, minute attention to the cor- respondence of the symptoms is of more importance than any par- ticular symptom; thus, the peculiar oppression which accompanies a high degree of fever is familiar to every one, and is not reckoned an unfavorable symptom; the same degree of oppression occurring with- out fever, or with very slight fever, would indicate a head affection of the most dangerous character. In the same manner, a degree of headache and of delirum, 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 modifications is that which comes on with a sudden attack of palsy, so as to be considered as an apoplectic rather than an inflammatory affection: it is generally connected with inflam- mation 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 head- ache, often confined to one side of the head—loss of memory—affec- tions of various organs, as the eye, the ear, or the tongue—convul- sive 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 color, 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 sen- sible to the last, and in others it is unusually contracted; sometimes, after being dilated and insensible, it again becomes sensible: occasion- ally one pupil is found to contract, while the other is dilated and in- sensible. 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 one of the cases to be afterwards described. Remarkable recoveries of the senses also occur, often a short time before death. Some time ago I saw a boy aged seven, who had per- fect 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 re- lapsed into coma, and died next day. The usual appearances were found on dissection, the effusion being in large quantity. I have also seen squinting continue for a day or two, and then disappear, the dis- ease running its course to a fatal termination without any recurrence of it. J SYMPTOM*. 27 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 sometimes easily regulated, and some- times 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 appearence 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 danger- ous. Every practitioner who divests himself of system, and attends to what is passing before him, will find, that the character of stools here referred to, is by no means peculiar 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 evacuations, and every means used to correct them when they are morbid, I must con- sider it as erroneous in principle, and in practice dangerous, to suppose that any particular character of stools is characteristic, of hydrocephalus. 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 patho- logical 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 in the seat of the inflammation may be referred to the following heads. I. The Dura Mater. II. The Pia Mater and the Arachnoid. These may be taken to- gether, both because it is extremely difficult to distinguish 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. 28 INFLAMMATORY AFFECTIONS. 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 pecu- liarities 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 membranes, 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 attached to the effusion, as if it alone constituted the disease called acute hydrocephalus. The symptoms were ascribed to the compressing influence of the ef- fused fluid, and the practice was directed chiefly or entirely to promot- ing its absorption. It is now, I imagine, very generally admitted, that the effusion in acute hydrocephalus is to be considered as one of the terminations of inflammatory action, though there are certainly 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 immediate- ly adjacent to it. In this manner we see effusion take place in the cavities of the F*Ieura, 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 seat 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 sec- ondary manner. We observe the same varieties in the appearance of the effused fluid in the brain, which we find in the other serous cavi- ties; and upon the whole view of the pathology of the disease, we may consider the principle as fully established, that inflammatory action is the source of the effusion in all those accute affections of the brain, which have generally been included under the term acute hydroce- phalus. (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 be- TERMINATIONS. 29 come oedematous below the seat of the pressure, and we find ansarca of the whole or part of a limb produced by the pressure of tumors, and ascites arising from induration of the liver. Whenever such in- terruption occurs in the circulation of a vein, it appears that increased effusion takes place from the exhalant branches of those arteries with which the vein is more immediately connected, depending probably upon a state of congestion in these parts, which in its effects is near- ly 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 tumors, chronic disease of the sinuses, tumors 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 Hydrocephalus and Serous Apoplexy. In regard to its seat, the effusion of course varies in different cases. It is found in the ventricles,—under the arachnoid,—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 situation escapes when the head is opened. It is occasionally met with in a cavity formed by the separation of the la- minae 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 lake place in consequence of the obliteration of the communicating opening. In quantity, the fluid varies from a few drachms to eight or ten ounces, or more. As to quality, it is sometimes limpid, sometimes bloody, and sometimes tur- bid, containing shreds of flaky matter. In some cases it is seen in the ventricles exhibiting all the sensible qualities of pus. Generally, how- ever, it seems to contain but a very small proportion of animal matter, In the experiments of Dr. Marcet, a thousand 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 inflam- mation 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 extent, communicating a yellow color 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 convolutions by small triangular projections; in other cases, it follows entirely the course of the pia mater, producing complete adhesion of the convolutions to each other. It is occasionally found within the ventricles, covering the surface of the choroid plexus; and a very common seat of it js the upper surface of the tentorium. 30 INFLAMMATORY AFFECTIONS. IV. By Suppuration.—A thin uniform layer of puriform matter is often found under the arachnoid, and occasionally between the arach- noid and the dura mater, and between the dura mater and the bone. It is also met with in distinct small cavities formed by partial adhe- sions of the membranes to the bone or to each other, and it is occa- sionally found in the ventricles. 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 extensive por- tion of the cerebral substance is found in a broken down corrupted state, in which, without any well-defined cavity, pus is found mixed with the disorganized cerebral matter. 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 medula oblon- gata, 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 softening of the brain, which has now received that name,—a term adopted from the French to express the peculiar morbid appearance; 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 color, but having lost its cohesion and consistence. It differs entirely from suppuration, having neither the color 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 observations is the dense white matter forming the corpus calosum, fornix and septum lucidum. The septum is generally found in such cases perforated by a ragged irregular open- ing, and the fornix has either entirely lost both its figure and its con- sistence, 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. When I formerly endeavored to contribute something to the patholo- gy of this remarkable affection, I had no hesitation in considering it as one of the results of the inflammation of the cerebral substance. Since that time, it has been investigated with much attention, by M. Rostan and other French pathologists, and a different view of the nature of the affection has been strongly contended for by these emi- nent individuals. They consider it as an affection of the brain en- tirely sui generis, and M. Rostan, in particular, seems to look upon it is 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 inter- esting affection, I think we are enabled to arrive at the conclusion, that it occurs under two modifications which differ essentially from TERMINATES. 01 each other. In the cases of M. Rostan, the disorganization was ob- served 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 ihem 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 extra- vasation 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 im- mediately surrounding the ventricles; and occurred in persons of va- rious ages, but chiefly in young people and in children. It took place in connexion with attacks of an acute character, chiefly the charac- ter of acute hydrocephalus; and it was in many cases distinctly com- bined with appearances of an inflammatory kind, such as deep redness of the cerebral matter surrounding it, suppuration bordering upon it, and deposition of false membrane in the membranous parts most near- ly 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 in- flammation, and probably exhibits, as we trace it from one extremi- ty 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 ramollissement, was entirely surrounded by a ring of inflammation. This is the affection which I have endeavor- ed 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 observations 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 peculiar softening of the cerebral matter is analogous to gangrene in other parts of the body; and that like gan- grene 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 described, and the latter to be the source of the appearances described by M. Ros- tan. 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 concomitant 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 appearance in elderly people, and seems to be a very frequent source of apoplexy with extravasation of blood, at advanced periods of life. It appears 32 INFLAMMATORY AFFECTIONS. extremely probable that it may be the source of that particular con- dition of a part of the brain which terminates in the ramollissement oi M. Rostan, and indeed he distinctly points at this explanation of it. On the other hand, I am still disposed to contend, that the ramol- lissement of young persons, occurring in acute affections, and seat- ed chiefly in the central parts, is one of the terminations of inflam- mation in that particular structure. I conceive it to be an affection of primary importance in the pathology of acute affections of the brain, and to mark a peculiar seat of the inflammation of very fre- quent 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 appearance, 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 of a part of its substance, and similar softening of the fornix, were the only morbid appearances in cases which were fatal with all usual symp- toms 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 particularly 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 terminations are scarcely less fre- quent; particularly the ramollissement 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 hydrocephalus. Other cases, in which the symptoms closely resemble those of hydrocephalus, will be found to terminate by the undefined suppuration, or by this combined with serous effusion, or with the ramollissement of the central parts. In fact, we do not often meet with any one of the terminations uncombined, and it is impossi- ble to anticipate from the symptoms, in what manner the disease may terminate in any particular case. Serous effusion, uncombined with any other morbid appearance, I have usually observed in that which I have described, as the fourth form of the disease, in which the symptoms as slow and insidious in their progress, and at no period exibit 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 ramollissement 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 encyst- TERMINATIONS. 33 ed abscess or the deposition of false membrane between the arachnoid and pia mater. But these results are by no means uniform; and the ramollissement in particular may occur with very slight and insidious symptoms. The various terminations, indeed, are very often com- bined together, and all of them are generally combined 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 be- lieve, that the darker or cortical parts of the brain are the chief seats of suppuration, 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, depending proba- bly upon the constitution of the patient. Thus, in some cases, we find it assuming the highest characters of active 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 grada- tions. Without attempting any general conclusions on these points, I shall proceed to describe a. selection of cases calculated to illustrate the various modifications of inflammation of the membranes and of the substance of the brain. SECTION III. INFLAMMATION OF THE DURA MATER. Idiopathic inflammation of the dura mater is a very uncommon af- fection; 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 the 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 tem- ple, but it was not severe; and her whole appearance corresponded with that of mild continued fever, though with some characters of an affection of the brain. After general and topical bleeding, with pur- gatives, &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 disease passed, with much of the charac- ter of continued fever; the tongue white, the pulse varying from 96 to 110, the nights sometimes quiet, and sometimes restless. In the begin- ning of the second week, a swelling appeared in the left upper eyelid; 34 INFLAMMATION OF THE DURA MATER. 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, fol- lowed by heat and perspiration, for which an eminent physician or- dered her the bark in large doses. For two days after this she seem- ed 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 open- ing 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 headache, with an oppressed look, and the pulse varied exceedingly, 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 re- marked in the symptoms. Between one and two in the morning, she was observed 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 complained of dimness of sight, but none of these symptoms had been taken notice of. Inspection. On raising the skull-cap a good deal of purulent mat- ter 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 adventitious membrane, by which the du- ra 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 hemis- phere. The dura mater included within this space was depressed; 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 surface of this portion had the same irregular ul- cerated appearance as the outer surface, and when held up to the light, the membrane at the part appeared to be in some places considerably 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 re- moved, an extensive stratum of adventitious membrane was "found un- der the arachnoid. It was irregular in thickness, being most remark- able 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 IDIOPATHIC. 35 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 color, but without any change of structure. There was no effusion in the ven- tricles, and the brain in all other respects was quite healthy. The suppuration 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 mater appears to have been the primary disease, though it was afterwards complicat- ed with extensive inflammation of the arachnoid. The only case which I have met with in any degree analogous to it, is one which is mentioned by M. Fizean, though it differs from it in being complicat- ed 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 entirely the eye and its dependencies. He then had irregular attacks of fe- ver, 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 swelled so as to close the eye, and on raising it the eyeball appeared unusually prominent. He had nausea and severe headache, but was quite sensible, and the fever was mod- erate; 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 of the forehead were im- bued with purulent matter; the frontal bone was denuded and cari- ous 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 beyond the nose. The dura mater was detached and covered with pus over a space corresponding with the external, disease, but it was not detach- ed 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 dina mater. A man aged 62 had violent pain in the upper part of the head, which suffered re- missions. When he was first visited, this had: continued five days; —there was then considerable torpor, with weakened memory, aud some confusion of ideas, but no fever.—Under the usual treatment, the symptoms went on for a fortnight, with little change, unless that (here were attacks of fever, and gradual loss of strength. The symp- * Journal de Med. torn. xi. new series, p. 523, 36 INFLAMMATION OF THE DURA MATER. toms 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 diminished, the man was out of bed, recovered his appetite, and appeared to be in all re- spects better. A few days after this, he complained of extreme weak- ness, and suddenly expired. The whole duration of the case was about a month. On puncturing the dura mater, turbid fluid tinged with blood was discharged 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 thickened 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 color, rugose and unequal, with adhesions to the arachnoid. The arachnoid also was thickened and opaque on the upper part of the hem- ispheres. These are the only cases that I am acquainted with of idiopathic inflammation of the dura mater taking place in this manner; but the disease is frequently met with in another form. It occurs in connex- ion with affections of the ear and of the petrous portion of the tem- poral bone. This insidious and highly dangerous affection generally begins with pain in the ear, and for some days may be considered merely as a common ear-ache. Sometimes discharge of matter takes place from the ear, which is expected to relieve the pain; but the pain contin- ues or becomes more violent. The patient becomes oppressed and drowsy, then slightly delirious, often with shivering, and at last coma- tose. 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, be- comes 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 superficial 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 IDIOPATHIC. 37 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 interme- diate stage of its progress, the fatal event having taken place from another affection. Case II.—A gentleman aged 20, on the 20th January 1820 com- plained of violent toothache, seated in a tooth on the right side of the upper jaw. On the 21st, the pain extended into the ear, without any other symptom. On the 22d, the pain continued in the ear, and extended toward the temple. He lay in bed part of the day, but got up afterwards. Leeches were applied, and he took some laxative medi- cine, which he vomited, 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. [n the night he became incoherent and delirious; he was then seen by a surgeon who found him c< nsiderably incoherent, but complaining of severe headache; the pulse 70 and of moderate strength. I saw him on the 24th; his pulse was then sixty, his face rather pale; the head- ache continued, and was chiefly referred to the forehead; his look was vacant; he answered questions distinctly when he was roused, but talked incoherently when his attention was not kept up. He was now treated by repeated general bleeding, which he bore well; cold applications, blistering, purgatives, &c. On the evening of the 24th, there was considerable shivering. On the 25th, there was less com- plaint 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 spok- en to, lay either in an oppressed state, or talking incoherently; 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 yel- lowish slough. In the course of this day, the mouth was at times observed to be drawn to the left side, especially when he was drink- ing. 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 extensive ramollisse- ment of the septum lucidum, the fornix, and the cerebral matter border- ing 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-colored; and the petrous portion was dark-colored, very soft, and when cut into, discharged matter from its cancelli and from the cavity of the ear; the dura mater corresponding to the tem- poral bone was much thickened. The part of it which lay anterior to 38 INFLAMMATION OF THE DURA MATER, the petrous portion was in a state of recent inflammation; the part behind the petrous portion was much thickened and spungy; and be- tween it and the bone there was a deposition of thick purulent matter. From this place the disease had spread along the tentorium, and over nearly the whole surface of the cerebellum, on almost every part of which there was a deposition ofcoagulable 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 suppuration of the ear, which were usually preceded by severe pain and some fe- ver. She suffered one of these attacks in the left ear in July 1810, from which she was not relieved, as formerly, when the discharge of matter took place, but continued to be affected with pain, which ex- tended 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, impatient of light, and some vomiting; her look was oppressed, and the pulse 84. Bloodletting, purging, blistering, and mercury, were employed without relief. On the second day, the pulse was 60; on the 3d, there was slight and tran- sient delirium, a degree of stupor, and slight convulsions. She com- plained 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 mourning 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 un- der 90. The left ear had continued to discharge matter, and an open- ing had formed behind the external ear, from which also there was a purulent discharge. Inspection.—A considerable quantity of colorless fluid was found in the ventricles of the brain. The brain in other respects was heal- thy. In the left lobe of the cerebellum there was an abscess of con- siderable extent, containing purulent matter of intolerable fetor. The dura mater, where it covered this part of the cerebellum, was thicken- ed and spungy, and the bone corresponding to this portion was soft and slightly carious on its inner surface; but there was no communi- cation with the cavity of the ear. The opening behind the ear mere- ly passed behind the external ear, and communicated with the exter- nal meatus. Case IV.—A young lad) aged 15, had been liable, for six or seven years, to attacks of pain in the right ear, followed by discharge CONNECTED WITH DISEASE OF THE EAR. 39 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 shiver- ing through the day, and in* the evening had headache 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 headache. On the 29th, some discharge took place from the ear, but without relief of the pain, which continued with violence on the following day. On the 1st of May, the pain was somewhat abated in the ear, but had ex- tended over the right side of the head; pulse frequent; general and topical blood-letting were employed with partial relief. I saw her on the 3d: the headache 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 lancet, but nothing was discharged. Topical bleeding, blistering, &c, were recommend- ed. (4th) Pulse in the morning 148, in the course of the day it fell to 84,—look of much languor and exhaustion. (5th) Dark-colored matter of intolerable fetor began to be discharged from the puncture which had been made behind the ear. The opening here was enlarg- ed, and a probe being introduced, the bone was felt bare and rough over a considerable space; headache much relieved, pulse natural. (6th) Great discharge from the opening, headache much relieved, pulse 112; complained of some pain in the left side of the thorax, and there was considerable diarrhoea. (7th) No headache; there was much discharge of fetid matter from the opening near the mastoid process, and a probe introduced by it, passed backwards and down- wards under 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 ac- count 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. 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 color; the tinge, however, was found to be entirely su- perficial. The right temporal bone, externally, was bare through a great part of its extent; internally, it was in many places rough and dark-colored, and there was some dark-colored 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 lateral sinus were considerably thickened through its whole extent, and the capacity of the sinus was very much diminished, by a deposition simi- lar to that which occurs in the cavity of an aneurism. The internal 40 INFLAMMATION OF THE DURA MATER, ear contained dark-colored matter. The left cavity of the pleura contained fully a pound of puriform fluid; the left lung was collapsed, dense, dark-colored, and covered by a coating of coagulable lymph. These examples will be sufficient to illustrate this insidious and dangerous affection; several analogous cases are mentioned by Itard, but they do not present any important varieties 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 purulent matter in the internal ear and in the Eustachian tube, with inflammation and thickening of the dura mater, and copious deposition betwixt it and the bone.* The termination of this affection by coma is sometimes sudden and unexpected: 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 apprehended, until one morning he was found in a state of perfect coma, and died in the afternoon. He was moribund when 1 saw him, and no exami- nation 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. Powell,f who had been liable to sup- puration 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 continued, with a fetid discharge. On the 10th day of the disease, after a violent paroxism of pain, he sunk rapidly and died. The pars petrosa was found black and carious; the dura mater cor- responding to it was black, sloughy, and separated 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 headache, and discharge 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 convulsions, and died. An abscess was found in the middle lobe of the right hemisphere of the brain, and another in the cerebellum. 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 * Itard, Traile des Maladies de l'Oreille. t Transactions of the College of Physicians, vol. v X London Medical Repository, March 1817. CONNECTED WITH DISEASE OF THE EAR. 41 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 affection, extremely tedious in its progress, and sometimes terminates 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 ulcerated, and the bone perfo- rated by the caries; and in this way alarming symptoms are sometimes unexpectedly relieved. The relief indeed is in general but tempora- ry: the patient continues liable to pain, followed by discharges from the ear, and at last dies comatose, often with gradual abolition of the fac- ulties, 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 hemisphere of the brain a cyst about three inches in diameter, containing thick dark-colored pus; the lower part of it rest- ed upon the petrous portion of the temporal bone, and there was an opening through the cyst, dura mater, and bone, forming a free com- munication betwixt the cavity of the abscess and the meatus auditorius extemus.* Examples, indeed, have occurred which would lead us to suppose, that in some such cases the relief is permanent. A young lady in Edinburgh, several years ago, after the usual symptoms in the head, had lain for three or four days in a state of perfect coma, and her situation was considered as entirely hopeless. Her medical at- tendants, paying their visit as a matter of form, were astonished to find her one day sitting up and free from complaint; a copious dis- charge of matter had taken place from the ear with immediate relief, and she continued in good health. It is, however, by no means cer- tain, 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 cavity of the tympanum is capable of producing symptoms of great urgency, especially if there should be any difficulty of finding an outlet. In a case of this kind by Itard, the matter, after urgent symptoms, escaped by the Eustachian tube, and, by constantly drop- ping 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 occurs 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 deliri- ous, and dies comatose. The ethmoid bone is found carious, the du- * Transactions of a Society for the Improvement of Medical and Surgical Knowledge, vol. iii. 6 42 INFLAMMATION OF THE DURA MATER, ra 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, delir- ium, 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 conclude with certainty that in these cases, the discharge of matter was from the cranium, as violent symptoms of the same kind have been known to occur from suppuration in the frontal sinus. 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 outwards 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 de- scribed 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 fe- ver, during recovery 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. But such disease may arise in any part of the bones of the cranium without external injury, and may be productive of symptoms analogous to those already mentioned. Some years ago, a remarkable case of this kind occurred in Edin- burgh, 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 un- der the temporal muscle, which communicated, through a carious per- foration of the temporal bone, with an abscess in the substance of the brain. Burserius mentions a woman who, after suffering for a fort- night severe pain in the left side of the head, was seized with swelling and inflammation on the left eyebrow, eyelids, and cheek. After sev- eral 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 comatose. On dissection, the ex- ternal suppuration was found to have penetrated to the bottom of the • Observat. Chir. Fas. 2d. + See Hill's Cases in Surgery, nnd Hist, de l'Acad. de Science for 1703—33. CONNECTED WITH DISEASE IN THE EAR. 43 orbit, betwixt the bone and the ball of the eye, without injury of the ball itself; internally there was an extensive collection of matter, which communicated freely with the cavity of the orbit. In some cases of this kind, the trephine has been applied with suc- cess ; and they have shewn what extent of disease within the cranium may be recovered from, when a free outlet is given to the matter. Morand mentions a monk who had been for some time affected with discharge of matter from the right ear, with violent pain extending over the whole right side of the head. A tumor 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 ap- plied at this place, and discovered a suppurating cavity within the cranium, which discharged a tea-cupful of matter ; the discharge di- minished gradually, and the sore was healed 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 discharg- ed 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, distinctly bounded by an adhe- sion between the dura mater and the arachnoid ; it discharged at the first opening about three ounces of matter, and the case terminated favorably, the parts being healed in about two months.f The dura mater appears to be much less liable to idiopathic in- flammation than the other membranes of the brain. Various 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 perfo- rated; 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 men- tioned in the Miscellanea Curiosa; and Haller found in several in- stances, the falx eroded by large openings, and the hemisphe-es of the brain at these places adhering to each other. As a result of inflammation of the dura mater, a circumstance occurs in Case IV. which is worthy of notice, and which I think has hither- to 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 principle morbid appearance internally. * Morand Opuscules de Chirurgie. t Nouveau Journal de Medicine, tome xij, 44 INFLAMMATION OF THE DURA MATER, Case V.—A young lady, aged sixteen, (3d August, 1816,) com plained of severe headache, 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 headache for a fortnight, and had been confined to bed for two days. Bloodletting, purgatives, blistering, &c. were empoyed on the third and fourth with considerable temporary relief. (5th.) Headache easier, some vomiting, and several severe attacks of shivering, pulse 112. (6th.) Pulse 84, headache severe, now con- fined 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; head- ache 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 minutely in- jected; the veins on the surface of the brain were turgid, and at one place on the posterior part there was a slight appearance of extrava- sation of blood under the pia mater. There was no serous effusion, and no disease in the substance of the brain. The left lateral sinus was remarkably diseased through its whole extent; when compressed, it discharged pus, and some thick cheesy matter; it contained no blood; its coats were much thickened, and its inner surface was dark- colored, irregular, and fungous; at one part the cavity was nearly ob- literated. The disease extended into the torcular Herophili, and af- fected in some degree the determination 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-colored 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 carious; the cells of it were everywhere full of purulent matter, and communi- cated 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. Pnchard 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 ,n her symptoms. He describes the left lateral sinus as being through its whole length filled pp by a substance very diffe- rent from a recent coagulum, and apparently consisting of a deposi- CHRONIC, WITH REMARKABLE THICKENING. 45 lion of lymph, which had become organized. It appeared so com- pletely to occupy the calibre of the sinus, as to have entirely imped- ed the transit of blood through it." There was no other morbid ap- pearance, excepting very slight effusion. * Dr. Bright found the late- ral, cavernous, and petrosal sinusis of the left side, full of a dark ill- conditioned pus, which also filled the jugular vein, as far as its junc- tion with the subclavian. The Symptoms were pain in the ear, fol- lowed bv much delirium, and extremely restless nights, and death af- ter about three weeks. A few days before death, there was a copi- ous 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 deposition of new matter betwixt its liminae. The following case affords an example of a very remarkable disease which appears to have been produced in this manner. Case VI.—A gentlema.i 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 prevented, he fell to the ground. In these attacks he did not lose his recollection, and he re- covered completely in a few minutes. Before the commencement of this complaint, he had been liable to severe pain in the head, and gid- diness, 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 in- creasing weakness of both his lower extremities. On the 1st of Au- gust 1816, he was attacked with hemiplegia of the left side, accompa- nied by headache and giddiness; the pulse was natural, and his mind was not affected. For four days he continued to be affected with the most complete 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 complained of giddiness, and noise in his ears, but had little headache. Bloodletting and the other usual remedies had been employed. On the 19th, there was consid- erable headache; on the 20th, he became incoherent; and on the 21st, fell into perfect coma, with some convulsion. On the 22d, he was considerably recovered, so as to know those about him, and to answer questions 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 tumor five and a half inches long, two and a hall broad, and about half an inch in thickness; it was formed by a separation of the lamina? of the dura mater, and a deposition of • Plicbard on Diseases of the Nervous System, p. 175. 46 INFLAMMATION OF THE DURA MATER, new matter betwixt them. This new matter was, at the posterior part, white and firm; in other places, especially about the centre of the tumor, 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 tumor lay from before backwards, along the upper part of the hemisphere,—the inner edge of it being about an inch from the falx; the dura mater all around it was consi- derably thickened, as were also the coats of the longitudinal sinus. The surface of the brain, where the tumor lay, was so depressed as to retain an impression of its figure; and, on the anterior part of the brain, the substance was considerably softened, with some appearance 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 inflammation of the dura mater;—and many of the circumstances of it are exceedingly re- markable,— particularly the absence of marked cerebral symp- toms, and the prominent complaints being entirely referred to the stomach. Case VII.—A gentleman of a cultivated mind, and an amateur 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 application to his professional pursuits; his sight became impaired, 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 principles, 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 headache, impaired sight, false vision, and occular spectra. The spectral illusions gene- rally 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, ex- cessively emaciated. Inspection.—A portion of the dura mater, about three inches by two, immediately to the left of the falx, and a little anterior to its ter- mination in the tentorium, was separated from the skull by a layer of coagulated lymph, imperfectly, or not at all organized, and of a dull yellowish red appearance. This portion of the membrane was glued CHRONIC, WITH REMARKABLE THICKENING. 47 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 depth of an inch and a half;—it adhered also to the falx, which w7as similarly diseased for nearly a square inch throughout its whole thickness; but did not ad- here to the right hemisphere 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 ventricles, and as much about the base of the skull. The stomach was not examined. This case is a striking example of extensive cerebral disease 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 appearances assumed, that about the time this gentleman became ill, his mind was intent upon making a drawing of one of the fanciful descriptions in JWoor'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 rela- tives, also sustained some injury of the head. This explanation, however, is merely conjectural. I have found nothing described by any writer precisely similar 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 remarable thickening of the dura mater at the base of the brain, in a young woman who had been liable to severe headache, 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 boy aged six, whose case is mentioned by Mr. Pais- ley,! 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 correspond- ing to the seat of the original pain, there was a tumor the size of a * Lancisi de Subitanies Mortibus. t Edinburgh Medical Essays, vol. iii. 48 INFLAMMATION OF THE ARACHNOID AND PIA MATER. 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 similar tumors, but of smaller size, along the course of the longitudinal sinus on the left side. Besides the fluid, the tumors contained a number of small white bodies like worms; at the places where the tumors were formed, the dura mater adhered very firmly to the membranes beneath. There was much effusion under the arach- noid 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 ihe affections are generally combined, 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 convolutions, we may suppose that it has been produced from the arachnoid; when it dips considerably between them, it is probable 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 vas- cularity, even when there is no deposition betwixt the convolutions, while there is seldom any remarkable vascularity observed in the arach- noid. On this ground it has sometimes been doubted whether the arachnoid be really the seat of inflammation. Some degree of this affection frequently accompanies other acute diseases of the brain, but we very often find it entirely uncombined, so that we are enabled to mark the symptoms more immediately connect- ed with it. In these, however, there does not appear to be any uni- formity. In some cases, it comes on with headache, 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 headache and vomiting, but in oth- er cases comes on without any warning. The convulsion is generally long and severe; in some cases, it passes immediately into coma, which afterwards alternates only with a repetition of the convulsion un- til 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 advanced period of the disease. MENINGITIS. 49 The following selection of cases will illustrate the principal phenom- ena connected with this important affection, both in children and in adults. To prevent circumlocution, 1 shall employ the term JWen- ingitis to express the disease, meat i ig thereby the inflammation of the arachnoid, or pia mater, or Lot'), 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 fortnight re- markably listless and inactive, and affected with frequent 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 headache; pulse 60. The convulsion occurred frequently during the following night, and in the intervals 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 complained of headache; pulse 120. July 1st.—The ordinary remedies having been adopted, he was much relieved; no headache; 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 103; functions natural; a good deal disposed to sleep. 5th.—Pulse 70; had an attack of vomiting, and complained much of his head; afterwards fell into a degree of stupor; was sensible when roused, but was impatient of being disturbed, and still com- plained of his head; eyes natural; repeated vomiting; 6th.—Perfect coma, with frequent convulsion; pulse from 120 to 160; he frequently lay with 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 membrane under the arachnoid. [t was in general about the thickness 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 hemispheres, which were partially glued together by it. The principal seats of this deposition were, the anterior part of both hem- 50 MENINGITIS. ispheres, and the whole base of the brain, especially the depressions 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 evidently 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 headache, and exclaiming that some person had given her a blow on the head. 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 headache, but the complaint excited no alarm. 23d.—Was seized with violent and long continued convulsion, 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 membranes appeared highly vascular as if inflamed, except where this appear- ance was concealed by a layer of yellow adventitious 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 hemisphere. It was in general of the thickness of a wafer, and in some places extended 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 colorless fluid in the ventricles. The sub-. stance ot the brain was throughout unusually vascular. Case X.—A child aged 2 years, 21st May, 1826, was suddenly seized in the morning with severe and long continued convulsion. It left her in a dull and torpid state, in which she did not seem to recog- nise 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 continu- ance. I saw her on the morning of the 23d, and while 1 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 prescribed by Dr. Beil- by, and the motions were dark and unhealthy. Farther purging was MENINGITIS. . 51 employed, with topical bleeding, 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 par- tially comatose state, with frequent starting, pulse frequent, but feeble, pupil rather dilated; she took some food. In the afternoon of the 23d, the convulsion returned with great severity; and on the 24th, there was a constant succession of paroxysms during the whole day, with sinking of the vital powers; 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 adventitious mem- brane, betwixt the arachnoid and pia mater. It was chiefly found above the openings between the convolutions, 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 through- out in the highest state of vascularity, especially between the convo- lutions; and when the brain was cut vertically, the spaces between the convolutions 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 appearance. § II.—Meningitis of unusually great extent, with very OBSCURE SYMPTOMS. Case XL—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. After the operation of some laxative medicine he was much relieved on the 24th; his pulse, however, con- tinued frequent. On the 25lh, he again complained of his bowels, and was feverish; but in the evening he was again relieved, and no symptoms was remarked by Mr. White, except that his pulse contin- ued 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, 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 frequent 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 surlace of the 52 MENINGITIS. brain was found to be covered by a continued stratum of yellow ad- ventitious membrane deposited betwixt the arachnoid and pia mater. It was thickest above the openings between the convolutions; in many places, it was traced dipping 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 convolu- tions. 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 presented no unusual appearance, but the pia mater showed throughout the highest degree of vascularity; the deposition was entirely confined to the space betwnen the mem- branes, for no vestige of it could be traced either on the outer sur- face of the arachnoid or the inner surface of the pia mater. There was no serious effusion, and the brain and the cerebellum were per- fectly healthy; the bowels were in many places irregularly distended with flatus. § III.—Meningitis of very small extent, with severe SYMPTOMS. Case XII.—A child aged 6 years, 24th January, 1822, had se- vere headache and some vomiting, followed by extreme obstinacy of the bowels, which resisted the most active medicines for six days. During this time, she complained constantly of headache, and the vom- iting recurred from time to time, but was not severe, the pulse vary- ing from 90 to 100. General and topical bleeding, with the most active purgatives and injections, had been employed with every pos- sible 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 symptoms, pulse from 80 to 90, and the headache nearly gone. This favorable state continued for two days; the headache then re- turned, and on the following day, the 13th of the disease, considera- ble hesitation of speech was observed, with slight delirium occurring at intervals. On the 14th, she was in these respects better, but still complained of headache, which was referred to the forehead; pupils dilated; pulse frequent. On the 15th, slight convulsion was remark- ed 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 headache; pulse 120. Through the day, the pulse 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 intermission for two hours, when she died. This very important case was most minutely attended to through its meningitis. 53 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, except a small part on the lower surface of the anterior lobe of the right hemis- phere, where it lies over the orbit. There was, at this place, a dis- tinct deposition of adventitious membrane of an extent scarcely lar- ger than a shilling. Immediately connected with it, the substance of the brain was sensibly hardened, 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 symp- toms resembling those of mild continued fever, which excited no alarm till about the end of the second week, when the headache be- came more severe, with some oppression and transient incoherence. I saw her, for the first time, in the beginning of the third week; there was then a degree of oppression, 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 or twice a degree of squinting was observed, but it went off; some- times 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 dis- ease. 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 depo- sition of adventitious membrane on the surface 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 towards 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. Tt began with fever, restlessness, and quick breathing; afterwards there were frequent convulsive affections, with much oppression, and at last severe convul- sions, squinting, and coma. At an early period of the complaint, there was observed a remarkable prominence of the anterior fontantelle; in the second week, this increased considerably; and in the third week, 54 meningitis. it was elevated into a distinct circumscribed tumor, which was soft and fluctuating,—and pressure upon it occasioned convulsion. It was opened by a small puncture, and discharged at first some purulent mat- ter, afterwards bloody serum. No change look place in the symp- toms, and the child died four days after. Inspection.—The opening which had been made through the fon- tanelle, was found to lead to a deposition of thick floculenl matter mix- ed with pus, betwixt the dura mater and the arachnoid, and covering the surface of the brain to a considerable extent. There was a simi- lar deposition between the arachnoid and the pia mater, which extend- ed between the convolutions, and there was a good deal of it about the optic nerves and under the medulla oblongata; there was considerable effusion in the ventricles. § VI.—Meningitis with suppuration within the ven- tricles. Case XV.—A child, aged 5 n onths, previously in perfect health, was seized with convulsion on the evening of the 21 st November 1817. The attack, which was not of long duration, was ascribed to dentition; the gums were divided over several teeth that appeared to be produ- cing irritation, and the other remedies were employed that are usual in such affections. He continued well through the night; on the 22d, he was oppressed, with quick breathing, and in the afternoon, without any return of convulsion, he fell into a state of coma. This contin- ued several hours, and then subsided, after topical bleeding, active purging, and the use of cold applications to the head. On the 23d, he was much relieved; eye natural; he took notice of objects, and was disposed to play, and no complaint was remarked, except occasional starting. On the 24th, he continued through the day in the same fa- vorable state; but late at night he was seized with convulsion, which continued without intermission through the night, and he died early in the morning. Inspection.—There was an extensive deposition of adventitious membrane betwixt the arachnoid and pia mater; it covered 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 ventricles 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 medulla oblongata, there was a similar deposition mixed with some purulent matter. There seems reason to believe that the arachnoid, lining the ventri- mening itis. 55 cles, is more frequently the seat of inflammation that has been com- monly supposed, in those cases which terminate either by simple effu- sion in the ventricles, or by the deposition there of a fioculent or pu- riform fluid. M. Gendrin has described several cases of this descrip- tion, in which the lining membrane of the ventricles was much thick- ened; and one in which the posterior part of both ventricles was lined with false membrane, 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 distinguished by any symptoms from the other inflam- matory affections. § VII.—Meninqitis of the cerebellum. Case XVI.—A lady, aged 45, liable to suppuration of the Jeft ear, complained of pain in that ear, May 11, 1821. On the two fol- lowing days, the pain extended through the head with fever; and on the 14th, she complained of general headache, and a violent and pain- ful 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 bloodletting 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 natural, the tongue clean, pulse 130; she still complained of headache when she was close- ly 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 ventricles; 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 cerebel- lum was highly vascular, the dura mater was healthy; there was some purulent matter about the pituitary gland, and in the cavity of the ear, but there was 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 uncom- mon affection. An interesting example of it is mentioned by Mr. 56 meningitis. Duglison in the London Medical Repository. A boy aged 5, pale and delicate, after being slightly indisposed for four or five days, was seized in the night of 9th August with violent convulsion. On the 10th, there was fever with delirium; a vacant look of the eye, and an evident imperfection 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. Ilth, 12th, 13th, and 14th, Symptoms gradually increasing; 15th, coma; constant motion of the right arm and leg; the left appeared to be paralized. In the night was seized with violent convulsion, 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 de- position of coagulable lymph. About § iv. of fluid was found in the base of the skull, but not above a tea-spoonful in the ventricles. These cases will serve to illustrate the remarkable diversity of symptoms which accompany this affection. 1 have selected them as calculated to exhibit the pure meningitis unconnected with any other considerable disease of the brain. The convulsive affections of children, which are apt to be indiscriminately ascribed to dentition, are, I think, frequently connected with this disease. In such cases, instead of the deposition of the 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 insidi- ous and highly dangerous affection, which I think has been little at- tended to by writers on the diseases of the brain. It is apt to be mistaken for mania, or, in females, for a modification of hysteria; and in this manner the dangerous nature of it has sometimes' been over- looked, until it proved rapidly and unexpectedly fatal. It sometimes commences with depression 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 confirmed form. This is in general distinguished by remarkable quickness of manner, rapid incessant talking, and rambling from one subject to another, with ob- stinate 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 MENINGITIS. 57 and coma; but in general it is fatal by a sudden sinking of the vital powers, supervening upon the high excitement, without coma. The principal morbid appearance is a highly vascular state of the pia ma- ter, sometimes with very slight effusion betwixt it and the arachnoid. The disease is one of extreme danger, and does not in general admit of very active treatment. General bleeding is not borne well, and the treatment must in general be confined to topical bleeding with purgatives, antimonials, and the powerful application of cold to the head. The affection is most common in females of a delicate irrita- ble habit, but also occurs in males, especially in those who have been addicted to intemperance. I have however seen it in one case, in a gentleman between 40 and 50, of stout make and very temperate hab- its. The cause of death is obscure; it seems in general to be a sud- den 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 had been 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 another 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; pulse from 80 to 90. In the evening she became sud- denly 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 symptoms con- tinued on the 6th; the pulse in the morning was little 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 afternoon, when she fell asleep. She awoke about eight, calm and collected, but with an evident tendency to co- ma; 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 continued to talk incohe- rently, but knowing those about her, and in general understanding what was said to her. Inspection.—The only morbid appearance that could be discovered was a highly vascular state of the pia mater, with numerous red points in the substance of the brain. Case XVIII.—A gentleman, aged 44, of a stout make, and very temperate habits, became suddenly affected, without any known cause, with extreme depression of spirits, accompanied by a good deal of talking and want of sleep. After this condition had continued for two 8 58 MENINGITIS. days, it went off suddenly, 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 without abatement for about four days, when he suddenly sunk into a state of collapse and died. Inspection.—The only morbid appearance was a highly vascular state of the pia mater and arachnoid, with slight serous effusion be- twixt them. This obscure and dangerous affection is sometimes met with in con* nection with other diseases, especially acute rheumatism and other in- flammatory affections, and sometimes attacks females in the puerperal state. It is unnecessary to give a lengthened detail of cases, which do not tend to throw any additional 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, 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 return- ed. I then saw her for the first time; she was talking a great deal wildly and incoherently, but, when her attention was arrested, she an- swered 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 symptoms. He was relieved by bloodletting, but his pulse continued frequeut, and he had some pal- pitation 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 unsat- isfactory. The above remarks on this highly dangerous and interesting 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 accouchmem, when, at the end of a fortnight, she became affected with a deep-seated hard swelling in the right side of the pel- vis, which was tender to the touch, and was accompanied by a con- stable degree of fever. After repeated topical bleeding and other remedies, the febrile state subsided, the swelling lost its tenderness MENINGITIS. 59 and seemed to be gradually diminishing in size; but its progress was very slow, and, after three or four weeks, she was still confined to bed, and suffering 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 occur- rence, and immediately began to talk wildly and incoherently, and after a restless night was found next day in a state of the highest ex- citement, talking incessantly, screaming and struggling, with a wild expression of countenance, and a small rapid pulse. She was treated by topical bleeding, laxatives, 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 counte- nance expressive of exhaustion. In consultation with a highly intel- ligent 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 per- fectly composed and rational, her pulse about 90 and of good strength; and from this time there was no return of the symptoms. The tumor in the right side increased in size, suppurated, was open- ed and healed favorably. From this time she continued in perfect health, and has since passed through another accouchement in the most favorable manner. This case I have given as another example of this interesting affec- tion. 1 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 particular cases to which the stimu- lating treatment is applicable. They appear to be those in which the excitement is accompanied 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 deterred from the practice, and in a considerable number of instan- ces 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 insani- ty, accompanied by paleness and bodily 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 inju- rious. An affection analogous to this occurs in habitual drunkards. The symptoms, in such cases, may either follow a particular instance of excess, or thev may appear in connexion with some incidental fe- brile disturbance produced by cold, or any other ordinary cause; 60 MENINGITIS. and sometimes they follow slight injuries. There is generally great irritability and restlessness, with sleeplessness . or disturbed sleep, sometimes delirium, almost amounting to mania: and generally a small rapid pulse. This state of excitement may either be followed by sudden sinking and death,—or it may pass into coma and be fatal more gradually. In other cases there is not the high delirium, but a febrile state of restlessness, passing into coma. On dissection, there is often little seen, except increased vascularity of the mem- branes, and some serous effusion under the arachnoid, and some- times a little in the ventricles. In other cases a deposition of puri- form matter is found under the arachnoid. 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 generally attacked with a succes- sion 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 dis- eases, especially hooping 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, ac- companied with fever, headache, and an obstinate state of the bow- els. 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 favorable form. Inspection.—There was slight increase of vascularity of the pia ma ter, 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 XXL—A child, aged 5, affected with hooping cough, on 5th June 1822, was seized with headache and fever; had afterwards ir- regular motion of the eyes with occasional squinting, then violent con- vulsions, which recurred frequently and alternated with coma; and he died m three days. After death, nothing could be discovered, on the most careful examination, except increased vascularity of the pia ma- ter in several places. ^™1IjXXIrTiArChlld-',aSed Uiree years and a"half' had he™ Tor several days slightly feverish, with some cough, but the complaint was donsideredastriW at table on the evening of the third of April, when she suddenly lost her speech, and soon after wards was seized with general convulsion. Sh/continued in a s ate MENINGITIS. 61 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 purgative medicine, which operated powerfully. On the 4th, the con- vulsion 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 inspection, no disease could be dis- covered, except increased vascularity of the membranes of the brain, and turgidity ol the veins upon the surface. I have notes of several cases resembling this in the symptoms, and presenting the same obscurity in the morbid appearances. They oc- curred 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 show 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 pri- mary affection had been so far advanced as to have the nature of it dis- tinctly 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 sub- siding, and on the day on which he died, he had been considered as convalescent by two medical men of the first eminence.. In the after- noon of that day, his mother observed that his eyes became suddenly fixed and vacant. Soon after, he was seized with most violent gen- eral convulsion, which continued, without intermission, for about five hours, when he died. Inspection.—There was considerable effusion in the ventricles, and a good deal of ramollissement of the septum and fornix. The only other morbid appearance was a most extensive and high degree of vas- cularity 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 suc- cession of symptoms, as the parts become successively affected. A lady, mentioned by Mr. Howship,* had severe headache, impatience of light, and paralysis of the left arm and leg. After a short time the • Howship's Practical Observations in Surgery and Morbid Anatomy. 62 M E N 1 N G I T I H • paralysis was removed, but the arm continufid so painlul as to be near- ly useless. The pain of the head continued, and, after two months, extended downwards upon the neck and back. She had then reten- tion 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 exhausted, four months after the commencement of the dis- ease. 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 medula ob- longata: 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 vari- ous 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. Powell*, after having been affected for a fortnight with slight headache, became incoherent, with a con- siderable 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 right side became paralytic. On inspection, effusion was found in the ventricles, and deposition of coagulable lymph about the pons Varolii. At the anterior part of the middle lobe of the brain—he 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, es- pecially where it lies betwixt the convolutions. This tubercular dis- ease of the pia mater does not appear to be a common affection, but a very remarkable case of it is mentiened by Dr. Clarkj. A man, aged 35, addicted to intoxication, was seized with fever and cough, followed by vomiting, bloody stools, drowsiness, and muttering; but he was not entirely confined for the first fourteen days; after this he became worse, with severe headache, much cough, subsultus, drowsi- ness and deafness, pulse 116, tongue dry and brown. He had then delirium, impatience of light, and a degree of coma; but he was re- lieved 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 be- fore. On inspection, the dura mater was found perforated by small orifices, which transmitted flesh-colored 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 * Transactions of the College of Physicians of London, vol. v. t Edinburgh Medical Journal, vol. v. p. 261. INFLAMMATION OF THE HEMISPHERES. 63 in depth. The arachnoid was thickened, and in some places aJ- liered to the pia mater; in other places, coagulable lymph was de- posited 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 inflammatory action of old date. Such cases are mentioned by Wepfer, Willis, and others, in some of which the patients had been long liable to headache. Similar appearances have been observed 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 entirely healthy. SECTION V. INFLAMMATION OF THE SUBSTANCE OF THE HEMISPHERES. In the symptoms accompanying inflammation of the substance of the brain, there are considerable varieties, depending probably on the ex- tent of the disease, and the particular part of the brain which is the seat of it. We find in some cases, headache, followed by high deli- rium, and this by coma; in others, a sudden attack of convulsion. A frequent and very important form of the disease is characterized by headache, followed by convulsion of one or more limbs, the affected limbs, afterwards becoming paralytic. Other cases assume a close resemblance to the ordinary attack of hemiplegia, so as scarcely to be distinguished from it; and a very interesting 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 inflammation terminates; in these we are chiefly to attend to the following varieties. I. It may be fatal in the inflammatory stage;—a certain defined portion of the cerebral substance presenting the appearance of deep redness without any change of structure. II. The simple ramollissement; which consists iu a part of the brain being broken down into a soft pulpy mass, retaining the natural color of the part, without any appearance of suppuration, 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 64 INFLAMMATION OF THE HEMISPHERES. diseased mass presenting the deep red color, while another is in the state of ramollissement. III. The preceding appearance mixed with a proportion of puru- lent matter. IV. The undefined suppuration. This might perhaps be consid- ered as a modification of the former, but with the purulent matter predominating in quantity. It presents a large ragged undefined cavi- ty, filled partly with fetid purulent matter, and partly with broken down cerebral substance, the surrounding substance being soft and disorganized. V. The defined or encysted abscess. This consists of a well de- fined regular cavity, filled with purulent matter, generally lined by a soft cyst, and surrounded by cerebral matter in a healthy state. VI. Ulceration of the surface of the brain. Important modifications also occur in connexion with the character of the disease in regard to activity. In particular, there appear to be some very interesting phenomena, connected 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 periodical character. These various modifications will be illustrated by the following selection of cases. § L--THE INFLAMMATION OF THE CEREBRAL SUBSTANCE FATAL IN THE INFLAMMATORY STAGE. Case XXIV.—A woman, aged 26, had labored under bad health in a variety of forms for 18 months before her delo.t»»s portion appeared rather firmer than the healthy cerebral substance, except towards the centre, where it was soft, as if approaching to suppuration. The external circular- CHRONIC FORM. 69 ence of the poriton retained the deep red color, to the depth of about half an inch; the central parts were of an ash color, with interspersed portions of a dark reddish-brown. On the upper surface, where the membranes adhered to it, there was a deposition of false membrane to the extent of the adhesion, and the dura mater, at the place of the ad- hesion, was thickened and spongy; the coats ofthe longitudinal 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 tubercular, and the pleura lining the diaphragm, on the left side was rough and irregular, from numerous small firm excres- cences on its surface, resembling warts. Case XXVIII.—A lady, aged 60, for whose case I am indebted 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 favorably, until the 8th of October, when she had another attack. She did not then beeome in- sensible, but complained of a strong pulsation over the body, partic- ularly on the right side, the arm and leg of which were again consider- ably paralysed. From this time, she gradually lost the power of these parts, first of the leg and then ofthe 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 frequent- ly carried; the bowels were extremely torpid. The usual treatment was employed by Dr. Hay, in the most judicious manner, without re- lief; her strength gradually declined, and she died on the 26th of De- cember, 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 firmly to the brain, at a spot about the centre of the left hemisphere, on the upper part. The substance ofthe brain beneath this portion seemed firmer than natural, and, when cut into, was of a bright red color. This portion was about an inch and a half in extent downwards, and of near- ly the same breadth; and the cerebral substance surrounding it appear- ed more vascular than the other parts of the brain. Deeper in the substance of the brain, a similar portion was met with, the size of a hazel nut, which was of a deeper red color than the former. The cor- pus striatum of the same side was of a red color, inclining to purple, soft in its texture, and presenting, when cut across, numerous points of vessels. The right hemisphere was healthy; there was a small quantity of fluid, in the lateral ventricles; and in both ventricles, the choroid plexus, was turgid with blood, and contained in its substance numerous small cysts of a bluish color. The vessels on the surface of the left hemisphere, and betwixt the convolutions, were verv 70 INFLAMMATION OF THE HEMISPHERES. turgid with blood; and, in some ofthe deeper convolutions, there was a slight appearance of ecchymosis. § III.--THE INFLAMED MASS PASSING INTO RAMOLLISSEMENT. Case XXIX. — A girl, aged 7, had been falling off for about two months before her death, having some cough, with considerable ema- ciation ; 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 com- plained of pain in her bowels, and had some cough. Three or four days after this, she complained of headache, 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 headache and pain of the ear ; with considerable embarrassment 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 continued fever. I saw her on the 30th, when there was considerable 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 headache. On the 31st, she was speechless, with nearly perfect coma ; pulse 80. She con- tinued in the same state on the 1st of August, with the pulse becom- ing 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 paralytic, or at least were never observed to move, even during the convulsions of the right side. These paroxysms continued 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 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 dipping down consid- erably betwixt them. On cutting through this hemisphere, a defined portion was met with in a state of recent inflammation, presenting a uniform red color, and a natural consistence. It was about 2 and a half inches in length, extending 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 color ; and the two structures evidently passed into each other, the inflamed portion becoming gradually softer as it approach- ed the softened part. Along the whole of that part ofthe hemis- PASSING into ramollissement. 71 pheie, through which the inflamed mass extended, all the convolutions were firmly glued together through their whole extent, by a deposition of very firm adventitious membrane; 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 annu- lare, there was an irregular tubercular of considerable extent, mixed with adventitious membrane. In the lungs there were numerous mi- nute 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 inflamma- tion. Case XXX.—A lady, aged 24, had long been liable to severe attacks of headache, which occurred at irregular intervals, and were excited by various causes, such as warm rooms, and bodily exer- tions, and for which she had used a variety of treatment with little benefit. They had not, however, affected her general health, and she was recovering favorably from her second accouchement, under the care of Dr. Mackintosh, when, about the beginning ofthe second week, she was seized with severe headache, and considerable op- pression. She was bled with relief, and continued tolerably well for several days, though with occasional complaint of headache. On Sunday, 14th January 1827, after a disturbed night, with some de- lirium, she complained in the course of the day of slight uneasiness in her head, and a peculiar feeling of numbness in the back ofthe head and neck; but she was otherwise well, and in good spirits, till about ten o'clock at night, when she suddenly complained of numbness and loss of power ofthe 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 immediately 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 power- less, and with a degree of spasmodic rigidity. A few hours after, the right leg became also paralytic. She continued without any farther change till about three o'clock in the morning, when she was seized with severe and general convulsion, 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 ap- pearance of sensibility. She had from the first swallowed with diffi- culty, but every attempt to make her swallow now excited general convulsion. During the attacks, the face was much distorted, and equally so on both sides; the limbs of the left side were violently 72 inflammation of the hemispheres. convulsed, while the right arm was affected chiefly with a rigid spas- modic contraction, and a tremulous motion. The convulsions now returned with great violence and frequency, sometimes every hall hour, and each attack continued for ten or fifteen minutes. The pulse was generally rapid; sometimes extremely feeble, and some- times of tolerable 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 being with- in a few minutes of death; but she continued to live in this slate till the evening ofthe 16th, being forty-eight hours from the attack. On the second day, the rigid contraction of the right arm had disappear- ed, and it continued entirely paralytic, except when it was affected by the convulsion. Inspection.—On the upper surface of the left hemisphere, and be- tween the convulsions, there was a considerable ecchymosis, produc- ed by a very thin layer of extravasaled blood betwixt the arachnoid and pia mater. The veins on the upper 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 diminu- tion of its area, arising partly from the thickening of its coats, and partly from deposition of firm white matter on its inner surface. In the substance of the left hemisphere, about the centre of its long di- ameter, towards the outer side, and rather above the level of the ven- tricle, 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 color; and immediately bordering upon this part, there was a considerable portion in a state of the deep redness de- scribed in the former cases; the brain in other respects was healthy, except a small softened 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 action of the heart, dropsical symptoms, and irregular pulse: after some time he was con- siderably relieved, but about a year and a half after this, he again be- came dropsical, and about this time was suddenly seized with palsy ofthe left side ofthe 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 ac- tion ofthe heart continuing, with small irregular pulse, and much dys- pnoea. In May 1821, he was again attacked with palsy of the left PASSINO INTO RAMOLLISSEMENT. 73 side, accompanied by coma and delirium, and recovered in a few weeks. In these two attacks of palsy, there never had been any com- plaint of headache; but in March ls23, he was attacked with severe headache, followed by loss of memory, palsy ofthe left side, and co- ma. He again recovered in a few weeks, so as to be able to walk about; the symptoms in the thorax continued as before. 20th Octo- ber 1S:>.{, he was a fourth time attacked with palsy of the left side, accompanied by violent pain referred to a particular spot on the coro- nal suture, a little to the right side. This was followed 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 little assistance, dragging his leg, but continu- ed to be occasionally 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 December. Inspection.—There was nothing unusual on the surface ofthe brain, and no effusion in the ventricles. The right corpus striatum was ex- ternally of a peculiar dull yellow color, and when cut into was found to be throughout its whole substance in the extreme state of ramollis- sement, extending to a great depth; this was mixed with a slight ap- pearance 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 gene- rally and considerably enlarged; the right ventricle thickened; the left ventricle enlarged without thickening; the left auricle much enlarged, and containing a large organized polypus firmly attached to its sides, and deposited in successive layers like the deposition in the sac of an aneurism. § V.--TllE AFFECTION IN A CHRONIC FORM, WITH RAMOLLISSE- MENT OF SMALL EXTENT, AND REMARKABLE SYMPTOMS. Case \XXII.—A gentleman, aged 26, of a plethoric habit, had suffered occasionally for two or three years from headache and vertigo, which were always relieved by depletion. On 12th April 1827, while walking out, he was seized with confusion and giddiness, embarrassed speech, and a considerable degree of paralysis of the right leg. He was rather pale; his pulse was 70 and soft; and he did not complain of any headache. The usual treatment was adopted with activity by Dr. Combe of Leith, without much relief. On the contrary, after sev- eral days he began to complain of acute headache, accompanied by vomiting and hiccup; and the other symptoms continued nearly as be- fore,—his speech being labored and slow, and his memory very defective1. After some weeks these symptoms subsided, so that he was able to walk out; but the headache continued with frequent vom- iting. The pain was chiefly referred to the left side of the head, sometimes to the occiput, and there was occasional numbness of the 10 74 INFLAMMATION OF THE HEMISPHERES. right arm. When I saw him, along with Dr. Combe and Dr. Kelly in July, his chief complaint was of frequent and irregular attacks ol vomiting, occurring daily, or repeatedly during the day. It came on very suddenly, without previous nausea, and he was often awakened in the night by the sudden attack of vomiting. He had now a pale sickly look; there was no paralytic affection, and little complaint of headache; though he still had occasional uneasiness in the head, some- times referred to one part of it and sometimes to another. When he did refer it to a particular part as the principal seat ofthe pain, it was either the left temple or the occiput. But the headache at this time was slight and transient, and the symptoms in the stomach were so much the more prominent, that it was a matter of much doubt whe- ther 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 debility, great listlessness, and bad appetite; pulse little af- fected. 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 ac- complished this he walked with tolerable firmness. The symptoms went on in this manner till the 27th of October, when he was sudden- ly seized with violent and continued convulsion, and died in nine hours. Inspection.—In the substance of the middle lobe of the left hemis- phere of the brain, about the level of the lateral ventricle, there was a portion in a state of complete ramollissement, about an inch and a half in length, and an inch in its other dimensions, and the neighbor- ing parts appeared unusually vascular. The tuber annulare and pons Varolii were softer than usual, but otherwise healthy. No other mor- bid appearance could be discovered in the head, and all the other vis- cera were healthy. It is unnecessary to point out the very remarkable features of this case. The sudden attack so closely resembling the ordinary paralytic attack, must have been connected with the commencement ofthe in- flammatory stage. The remarkable symptoms in the stomach in the farther progress ofthe disease, and the mode of its termination, make it altogether a case of great value in the pathology of this remarkable affection. 1 he following case shows the same morbid appearance, with a tram of symptoms considerably different, but with a remarkable similarity in the mode of its termination. h;cC^^XIlL~;A Sent!ema,n' a§ed 38> duri"g tw° years before his death had suffered several epileptic attacks, from which, however, Sr 1827W7p T f Y r/CTrf- ^ thG m°minS of 27th ^em- side H™ ^id m bed»ReecuMe» ^ Paralytic on the right ?««»; a- rec°vered h,s sPeech >" ^e course of the day; the palsy continued in the usual manner, and after some time he began to e- CHRONIC, WITH RAMOLLISSEMENT, &C. 75 cover a degree of motion ofthe 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 considerably 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 considera- ble distance, though with a dragging motion of his leg, and could nearly raise his arm to his head. In the evening of 22d February he went to a supper party, and seemed remarkably well; but departed considerably from the abstemious regimen to which he had been pre- viously restricted. About 8 o'clock on the morning of the 23d he was found in bed in a state of complete insensibility, accompanied by se- vere and general convulsion, which was strongest in the limbs of die right side. The face was much convulsed, the eyes rolling and in- sensible, the respiration laborious and convulsive. Blood-letting and the other usual means were actively employed without any relief. The convulsion continued unabated in the state now described, when 1 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 ventricles 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 defined portion in a state of complete and dif- fluent ramollissement. The portion thus affected was about an inch in depth; about half or 3-4ths of an inch in diameter at the upper part, and bacaniB 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 disease could be dis- covered 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 as- certained, and faithfully related, to be illustrated by farther observa- tions on this very remarkable disease. § VI.—The affection in a chronic form, with exten- sive 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 suddenly fell down deprived of sense 76 INFLAMMATION OF THE HEMISPHERES, and motion, and paralytic on the leftside, 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 with- out 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 to the seat of fixed uneasiness. During this time his pec- toral complaints had disappeared. In January 1820, he began to improve, so as to have less uneasiness 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 continued without farther change till the 15th of Febru- ary, 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 speech, but the power of swallowing was permanently lost, so that from this time he was constantly fed by liquids introduc- ed into the stomach through an elastic gum tube. He was now quite distinct, and did not complain of any pain; the cough again abated; pulse of the 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 pow- er of swallowing; speech and intellect entire. He died rather sud- denly on the 20th of March, having the day before become extreme- ly weak and pale without any obvious cause. Inspection.—On removing the dura mater, there appeared on the middle ofthe right hemisphere a remarkable depression, which, when cut into, was found to arise from an extensive mass of pure ramol- lissement; 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 ventricles, 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 appearance 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 coagulable lymph, forming a thick firm mass betwixt the right lung and the pleura costalis at the lower part immediately above the dia- phragm. § -iL—Ramollissement combined with suppuration. Case XXXV— A man, aged 24, had been liable for two years WITH UNDEFINED SUPPURATION. 77 to headache, which was always referred to the right side ofthe head. In February 1818 he contracted syphilis, which, being neglected, be- came inveterate, and continued fourteen months. During this time the headache became more severe, and was always referred to the right temple. In June 1819, he was affected with numbness of the left thumb, which gradually extended over the arm, and he had after- wards 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 copius bleeding, &c. and was completely recovered within a month. In August, he was affect- ed in the same manner, and again entirely recovered. He continued well till 27th November, when he complamed 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 sensi- ble, and expressed his feelings by signs; pulse 98, small and irregular. There was no change on the 28th; and 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 hemisphere was extensively diseased, forming a mass in which softened cerebral matter was mixed with pus of intolerable fetor. There was very little fluid in the ventricles, and no other disease 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 affected 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 dis- charged more than a year and then healed, leaving a deep cicatrix. From this time he was liable to headache, which became more severe in the beginning of the year 1813. May 14, 1813, after having been for some days languid, and com- plaining a little of his head, he was seized with severe headache and frequent vomiting. He was much oppressed, and lay in a dozing state, impatient of being disturbed; pulse 60. He was treated in the usu- al manner, by free, general, and topical bleeding, purgatives, blister- ing, &c. On the 15th the headache was still violent, but the vomit- ing had abated; pulse 60; had several severe attacks of shivering, was oppressed and disposed to sleep, but sensible; eyes natural. (16,) Headache relieved; increasing oppression. From this time he lay in a stale of partial stupor, with much talking, which was generally cohe- rent; pulse varying from 80 to 120. He died on the 22d, rather un- expectedly, and without perfect coma. He had continued to know the persons about him till about twelve hours before his death. His sight continued natural except on the day of his death, when he ap- 78 inflammation of the hemispheres, peared to be blind: no paralytic affection, and no convulsive symptom had been observed. Inspection.—The right hemisphere of the brain, to about hall 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 XXXVIL—A gentleman, aged 18, (10th July, 1815,) was affected with violent headache, 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 blood-letting, purgatives, blister- ing, &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 headache 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 questions 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 hemis- phere 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 anterior lobes. There was a very small quantity of fluid in the ventricles, and considerable ramollissement of the formix. In the substance of the brain, near the base, there was a small tumor of an ash-color, which contained a cheesy matter approaching to suppuration. A portion of the dura mater covering the temporal bone behind the auditory portion was thickened and spongy, and there was slight appearance of caries in the portion of the bone with which the diseased membrane was con- nected. 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 puerperal convulsions, after which the patient lay for seven days, with very obscure symptoms, and sensible, till she died suddenly after violent convulsion. WITH ENCYSTED ABSCESS. 79 § IX.—Extensive undefined suppuration with extrava SATED BLOOD. Case XXXVIII.—A man, aged 40, fiad 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 convulsive motions in ihe right arm and leg, which attacked him in paroxysms, and usually continued about a minute, leaving him in the intervals able for his usual employment as a blacksmith. After blood-letting 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 considerable torpor ofthe right side. After some time, this was attended with motions, in the right arm and leg, exactly re- sembling 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 inarticu- late, and afterwards gradually lost, so that after the middle of June he never was able to articulate a word. His pulse, which till this time had continued quite natural, now became a little frequent; he passed his urine and feces involuntarily, but his mental faculties seem- ed 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 hearing 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 fre- quently shed tears. He continued in this state till the end of July, when he became comatose, and died in three days. Inspection.—On removing the dura mater, the left hemisphere 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 remainder of the hemisphere was found nearly reduced to a fluid mass, partly consisting of purulent matter, and partly of cerebral substance, in a soft pulpy state; but the greater part was purulent. From this mass of disease, the ventricle was sep- arated 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 walnut. X.—The encysted abscess. Case XXXIX.—A girl, aged 11, thin and delicate, after having complained for some days of headache, was seized on the 11th of Jan- uary, 1817, with convulsion, which continued about half an hour. I saw her on the 12th, and found her affected with severe headache, and paralysis of the right arm, which had taken place immediately after SO INFLAMMATION OF THE HEMISPHERES, the convulsion. The pulse was 100; the tongue foul; the face rath- er 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 headache was much abated, and she had recovered considerable motion of the arm. On the 15th the headache being increased, and the arm more paralytic, she was bled again; and on the 16th and 17th, she was much relieved, the pulse nat- ural, and the motion of the arm much improved. On the 18th, after being affected with increase of headache, and some vomiting, she be- came convulsed, the convulsion being confined entirely to the head and the right arm . The head was drawn towards the right side with a rolling motion of the eyes, the arm was in constant and violent mo- tion; she was sensible, and complained of headache; pulse 100. Be- ing bled to gviii. the convulsion ceased instantly, and the headache was relieved, but the right arm continued in a state of complete paral- ysis. (19th and 20th.) The arm had recovered a little motion; some headache continued, 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 state of perman ent paralysis. Hitherto no other part of ihe 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 employed with activity, without any effect in arresting the progress 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 convul- sion 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 re- maining motionless. February 4th. Complete paralysis ofthe whole right side; no re- turn of convulsion; she continued quite sensible, and made little com- plaint; pulse from 50 to 60. She now continued for several days without any change, and except the palsy of the right side, every func- tion was natural. She was quite sensible, appetite good, pulse and vision natural, and she made little complaint of any uneasiness. She was, however, 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 distinct 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 hemis- phere, very near the surface, and the other immediately behind it; they had no communication with each other, or with the ventricle. In the posterior part of the right hemisphere, there was a small ab- WITH FNCYSTED ABSCESS. 81 scess containing about Inlf an ounce of pus. There was no serous effusion in any part ofthe brain, and no other morbid appearance. Case XL. — A gentleman, aged 21, had been for many years af- fected with cough and puriform expectoration, which was often in considerable quantity; he had also had repeated attacks of haemop- tysis, some of them copious. He was stinted in his growth, and of a feeble habit, but in other respects enjoyed tolerably good health, and was able to attend to his business as clerk to a solicitor, till the be- ginning of July 1822, when he began to complain of headache. For some time before 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 headache, 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 corning down, and the headache being considerably relieved, though not quite gone. I saw him about the 15th. The pulse had then fallen to 50, he was feeble and languid, with some headache, 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 headache 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 puri- form 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 appearance 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 vvas still considerably dilated, though sensible to the light; a degree of headache centinued, 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 im- provement in his appearance, and much less headache, the pulse begin- ning 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 distinctly. He could still move the left arm, but slowly and with difficulty, and with an awkward mo- tion, somewhat resembling that of chorea, or as if he threw the wholo 11 82 INFLAMMATION OF THE HEMISPHERES, arm forward by a strong effort of the muscles of the shoulder; he had seldom attempted to move the leg for 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 upper 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 pos- terior part of the same hemisphere, there was another abscess rather smaller. These abscesses were distinctly defined, but not very dis- tinctly lined by a membrane, and the cerebral matter surrounding them was slightly softened. In the anterior part of the left hemis- phere, immediately 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 drams of pus, and another rather larger in the posterior part of the hemisphere. These abscesses were all above the level of the ventricles, except the one in the posterior part of the right hemis- phere, 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-colored mass, resembling the spleen, and internally presented 3 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 enlarged 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 w itb symptoms re- markably different from those mentioned in the preceding cases. Case XL I.—A man, aged 43, had complained of headache for ten days, but had not been prevented from following his usual employ- ment. 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 symptoms 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 con- trary, he made the most powerful resistance when Dr. Huie attempt- ed to bleed him, which, however, he accomplished to the extent of thirty ounces. In the afternoon there was considerable coma with stertorous breathing, but both these symptoms disappeared after an- other 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 coherent and quiet, pulse 108; but he became incoherent in the after- Sl°0°n' i ion I2?' henffasTTsometimes drowsy and sometimes rest- less; pulse 120 and small. He died in the night /nSpec*ion.-Three abscesses were found in the brain, all complete- WITH ENCYSTED ABSCESS. 83 ly encysted, and filled with well formed pus. The first was in the anterior lobe of the left hemisphere, and contained about three drams of pus. The second was in the posterior lobe of the same hemis- phere; 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 hemisphere, and appeared to be making its way towards the surface. A still greater obscurity of symptoms occurred in the following re- markable case, for which I am indebted to Dr. Allison. It occurred under his care in the Clinical Ward, in June 1827. Case XLII.—A man, aged 26, was seized with shivering, head- ache, 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 febleness and difficulty, his legs, particularly the right, being at each step dragged along, rather than raised from the ground; his expression was dull and list- less, but he said he was free from pain. A few hours after, he com- plained of violent pain in the occiput, with frequent vomiting. The pain was relieved by a bleeding. In the evening, he was oppressed, and answered questions slowly and with difficulty; there was still some headache, 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 extremely of a reddish-brown color. On the right side of the vertex, there was a spot the size of a half- crown of a greenish yellow color. On removing 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 ce- rebral substance of a livid yellow color. In the posterior part ofthe right hemisphere, there were two other abscesses, one in the cortical sub- stance, 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 surround- ed by a more defined cyst than any ofthe others; there was extensive ramollissement of the fornix, septum lucidum, and the lower part of the corpus callosum. The left corpus striatum was softened, and had a greenish-yellow color; the surface of the left thalamus was ragged and almost fluid, but retained its natural color. 84 ABSCESS OF THE CORPUS STRIATUM. § XL—Abscess of the corpus striatum of very small ex- tent. 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 been bled to the extent of 160 ounces in five days. For sometime after he felt his breathing a little uneasy, but this gradually subsided; and he enjoyed very good health till the middle of February 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 ofthe nose; he hod no other complaint; and no headache, 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 busi- ness than formerly, 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 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 indi- cate 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 ofthe 17th, he w7as heard to make a remarkable noise in his sleep, which was found to be owing to a kind of convulsive breathing. This was speedily followed 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 slightest 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 exceeding the size of a small bean, containing purulent matter of remarkable fetor. In the centre ofthe right corpus striatum, there was also discovered a minute abscess regularly and nicely 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 sustained 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 abscess of the medulla oblongata. 85 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 afterwards recurred occasionally. The use of the arm and leg was never entirely recovered. These always appeared weaker 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 symptoms, except con- siderable emaciation : the pulse was frequent, and the bowels very confined. Much dark-colored matter having been evacuated from his bowels, he seemed to be relieved. After some days, there was a remarkable slowness of the pulse', and in the course of the same day he was attacked with violent convulsion. This recurred several limes 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 ventricles of the brain. In the substance of the medulla oblongata, 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 color, 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 IS13, with inflammation of the bowels. The inflammatory symp- toms 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 variety of purgatives had been given, with repeated tobacco injections; and by calomel, given as a purga- tive, 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 complain of headache. This was at first slight, and, amid the urgency of her other symptoms, excited little attention. It increased, 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 1 1th, 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 headache continued unabated. On the 14th, there was a tendency to coma, which was increased on the 15th, with dilatation of the pupil. There was now little room for active treatment; and topical bleeding, blistering, &c. were employ- 86 ABSCESS OF THE CEREBELLUM. ed 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 a state of great oppression, but when reused talked sensibly; headache still severe. (18th) Had lost the power of swal- lowing, but often asked for drink, though she was nearly suffocated 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 suffocated in attempting it; was still quite sensible when roused, and complained of violent headache. She now sunk gradually, and died on the 22d; she had continued sensible when roused, and 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 substance showed marks of increased vascularity, and the ventricles were dis- tended with colorless fluid. The left lobe of the cerebellum was en- tirely converted into a bag of purulent matter, of a greenish color and intolerable fetor. It was contained in a soft and organized sac, which appeared to be of recent formation. A portion of the dura ma- ter on the outer side of the abscess was thickened and spungy; the bone was sound; the caput coli, and about eighteen inches of the ex- tremity of the ileum, were of a dark livid color, but sound in their structure. Another case of abscess ofthe cerebellum has been described un- der a former article.—See Case III. § XIV.—Ulceration of the surface of the brain. This appearance is uncommon, but it is distinctly described by sev- eral writers. A man, mentioned by Dr. Scoutetten, had violent head- ache, 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 vio- lent as to produce screaming. In this manner he went on without re- lief, and died on the twenty-sixth day,—no other symptoms being men- tioned, 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 ofthe brain, there was a superficial ulcer measuring 13 lines bv 7. It was of a yellowish appearance, and its edges were unequal and" ragged. The dura mater and pia mater covering the spot were destroyed by erosion, and the pia mater was in some other places inflamed; the brain in other respects 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 before his death with oedema ofthe forehead and left eyelid, headache, delirium, ulceration of surface of the brain. 87 '\\u\ convulsive motions of the upper extremities.' The same appear- ance in the cerebellum is mentioned 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 constant 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 hos- pital again, affected with pain in the forehead. It now became remit- tent, 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 became suddenly delirious in the night,^and soon after expired. On dissection, there appeared a general increased vas- cularity of the brain, without any decided disease, until the tentorium was raised, when there appeared upon the upper surface of the cere- bellum an ulcerated superficial excavation, the size of a shilling, con- taining a thin inchorous matter. The pia mater at this place was de- stroyed, and the dura mater was discolored. 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 ob- scure. In the other, the affection followed an injury of the pericra- nium, and was fatal after several weeks. The cases described under Section V. appear to illustrate the principal phenomena connected with inflammation ofthe substance of the hemispheres. In Case XXIV, we see it in its recent state on the surface of the brain, and in XXV. we find it in the substance forming a distinctly defined portion in a stale of active inflammation. In Case XXIX. we see an inflamed portion of this kind passing gradually into ramollissement; and in case XXX. we see the ra- mollissement in a more advanced state. In the subsequent cases, we see more complete ramollissement, 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 va- rieties of termination we at present know very little. I have thrown out a conjecture that the ramolissement occurs chiefly in the white matter, and suppuration in the grey; but it is mere conjecture. That the ramolissement however is a result of inflammation, I think the appearances 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 analogous to gan- grene 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 appearance. In the symptoms which accompany in- flammation of the substance of the hemispheres, there appears to be * Arch. Gen. de Med. January 1825, t Med. and Phys. Journal, March 1310. 88 INFLAMMATION OF THE HEMISPHERES, such a diversity as must prevent us at present from attempting any general statement of them. The most common appear to be head- ache followed by convulsions, either of one limb, or of a more gen- eral kind ; or a sudden attack of convulsion, without previous com- plaint of pain, the convulsed parts afterwards becoming paralytic. But in Case XXV. no paralysis was observed after three days of the most frightful convulsion ; while in Case XXX. paralysis was the first symptom, and convulsion 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 present 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 interest 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 inflamma- tion, ramollissement, suppuration, and ulceration ; and to some in- teresting 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 headache and convulsion; but in the more chronic form of it, as in Cases XXVII and XXVIII, we see it productive of paralysis without convulsion, and fatal in a state of simple inflammation, with all the symptoms of perfect apoplexy. On the other hand, in Case XXX., 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 convulsion of one or more limbs, followed by temporary paralysis, and that the permanent paralysis took place when the disease passed into suppuration. In some of the other cases, again, it seems proba- ble that the inflammatory state was productive of an attack of palsy, exactly resembling the ordinary hemiplegia from other causes. This probably took place in the very interesting case, (No. XXXIV.) 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 connect- ed with disease in the spleen. Tn 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 memo- ry was lost. She at last seemed to lose the power of every volunta- tary 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 illness, that Treutler. Auctarium ad Helminthologian Humani Corporis, p. 1. hEVIKW ol I HE SUBJFCT. 89 is, less than a month from the commencement of the symptoms in the head. In the posterior lobe of the right hemisphere of the brain, be- hind the lateral ventricle, a portion the size of a large walnut, (fructus regiae juglandis,) was in a state of high inflammation; the membranes adhered to the surface of the brain in several places; where this did not occur, 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 enlarg- ed; and extravasated blood, to the amount of several pounds, was found in the abdomen; it was contained partly in the cavity of the omentum, partly between the lamina? of the meso-colon, and partly under the peritonael coat of the descending colon. II. The Ramollissement of the Cerebral Substance does not appear to be characterized by any uniformity of symptoms. In particular, there does not appear to be any foundation for a state- ment 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 al- so met with in connexion with affections of the membranes, without any disease ofthe 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 favorably. Lallemand* remarks that he had taken up the idea of the rigid contraction ofthe limbs being diagnostic of ramollissement, and was very much per- plexed when he met with a case in which all the limbs were in a slate of the most remarkable relaxation. The cases which terminate by ramollissement seem in general 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 hemi- plegia 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. Tn some of the subsequent cases, again, we find most extensive de- struction ofthe cerebral substance, without either paralysis or convul- sion, and even without coma. In one remarkable case to be after- wards described, 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 * I.allen, and Recherches, sur l'Encephale 12 90 INFLAMMATION OF THE HEMISPHERES. ot health in which she had been for many months before her death, and was found dead on the morning. We find the same difficulty in attempting to ascertain the effect of ramollissement of particular parts of the brain, in producing 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 remarkably 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 ramollissement 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 headache, phrensy, convulsive motions, and sudden death; in the other, in which it was in the left lobe, there was loss of speech, with palsy ofthe right side, and stupor; it was fatal in eight days. III. In the cases which terminate by Suppuration, we find the same diversity of symptoms as in the cases now referred 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 purulent 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 obsure and unde- fined, 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, pro- bably occurred in the inflammatory stage, for when the symptoms were relieved by the bloodletting and other remedies, the arm re- covered its motion. The convulsion returned, and the paralysis along with it, and again subsided; and after several attacks of the same kind, the paralysis became permanent. The thigh and leg then went through the same course. In such a ease, 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 permanent 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 kg, must be matter of conjecture. In a similar case, related by BarthoKnus, 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 Schenkius, there occurred paralysis of the left side, and convulsion of the right; there was a superficial abscess on the right side ofthe brain. Something similar to this occurred in a case to be afterwards mentioned, (Diseases of Bones,) in which review of the subject. 91 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. Bate- man,* an abscess was found in the posterior part of the right hemis- phere, inclosed in a fine vascular sac, and containing four ounces of pus. She was first affected with convulsion of the whole body, which continued for nearly two days; during this time, the left side was in a state of rigid extension, and the right was in constant mo- tion; and when the attack subsided, the left side remained para- lytic. She then had headache, 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 de- scribed by Morgagni, the prominent symptoms were, pain of the left side of the head, delirium, loss of speech, and weakness of the mus- cles ofthe 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 indistinctness 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 regard to which it is unnecessaiy to enter into any lengthened detail. In a case by Lallemand there were cramps of the limbs, followed by a sudden attack ^ of palsy ofthe right side. After three days the affected limbs were seized with con- vulsions, which occurred for several days, and ended in fatal coma. Another case, by the same writer, began with pain in the right side of the head and tremor of the left arm. This was followed by a continued convulsive flexion and extension of the left arm, which after some days passed into palsy. There were then some convul- sive motions of the limbs of the right side; the abscess was in the right side of the brain. In a man mentioned by Broussais, an ex- tensive absess was found in the centre of each hemisphere, without any other symptom than a peculiar dulness of manner, writh tacitur- nity, 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 mat- ter or indurated cerebral substance. These have probably super- vened upon chronic disease of the brain, which, after continuing long in an indolent state, has at length passed into suppuration. In a few * Edin. Med. Journal, vol. i p. 150. 92 INFLAMMATION OF THE HEMISPHERES 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, with- out any symptom in the head. A man, mentioned by Dr. Powel, was received into St. Bartholomew's hospital on account of cough, dyspnoea and bloody expectoration. He died after he had been a month in the hospital, having been for some lime 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 diseased, and an abscess the size of a large walnut was found in the substance of the brain, under the anterior part ofthe 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 re- markable symptom was the loss of the power of swallowing. In a case by Plancus, there was paralysis 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 forehead, and this has been observed in other cases of the same kind. IV. The superficial ulceration of the brain appears to be a rare occurrence, and some ofthe cases of it present phenom- ena of rather an interesting character. A man mentioned by Dr. Powel,| was affected with a convulsive motion of the left side of his body, which very much resembled chorea; he was free from it dur- ing sleep, and had no other complaint. This affection continued five weeks, and then suddenly terminated in palsy of the affected side. Soon after 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 dis- ease, but much less extensive, on the anterior part of the left hemis- phere, and there was much fluid in the ventricles. A lady mentioned by Dr. Thomas Anderson§ of Leith, had been for several years lia- ble to headache, 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 occur- red in paroxysms, attacked her several limes every day, and general- ly continued about half an hour at each time. This complaint became gradually more and more severe; the right side became slightly affect- ed in the same manner, and she was afterwards liable to attacks of * Med. Trana. Coll of Phys. London, vol v. t Storia Med. d'una Postema del lobo destro del cwveiletto X Trans Coll. Phys. London, vol v, § Trans. Roy Soc Edin vol ii. review of the subject. 93 coma, in which she often lay for 24 hours at a time. She died at last of gradual exhaustion. On the upper part of the right hemisphere of the brain, there was a superficial loss of substance from ulceration, two and a half inches long, one and a half broad, and nearly an inch in depth. In the bottom of it there were were found some thin lami- nae of a firm brownish matter, with stony concretions, 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 caso 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 par- ietal bone, the depressed portion being forced through the dura mater, and driven inwards upon the brain. He had paralysis of the left side, and jthe left eye was insensible. The depressed portion being re- moved, the paralysis was greatly diminished, and the eye recovered a considerable degree of vision. On the third day after the operation, the wound in the dura mater was inflamed, with considerable tume- faction; and immediately the left leg and arm became paralysed, the paralysis being accompanied by convulsion; and the left eye also be- came again insensible. He had frequent convulsion of these parts for several days, the right side not being in the least affected, when, sup- puration 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 paralysis and fatal coma. A man men- tioned by Mr. John Bell, suffered, from an injury ofthe head, extensive extravasation of blood on the surface of the brain, which was remov- ed by repeated applications of the trephine. During the cure, which occupied three months, the left side of the brain suppurated five 01 six times. The attack of inflammation was always accompanied by fever, stupor, and difficult deglutition; but these symptoms were re- moved by the suppuration. These attacks occurred at various parts of the brain. When they were towards 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 vision in which a candle was seen with a halo around it. Ulceration of the surface of the brain I have seen only in one in- stance, 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 extent, with ragged edges, and sensible loss of substance. The affection occurred in a child of eighteen months, and was complicated with effusion in the ventricles, and ramollissement. The pia mater and 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 distinguished from those of hydrocephalus in its ordinary form. There were also nu- merous granular tubercles in the lungs, 94 INFLAMMATION OF THE HEMISPHERES. V. THE INFLAMMATION OF THE CEREBRAL SUBSTANCE OC- CURS in a chronic form, in which the symptoms may continue for months, and the disease then prove fatal by suppuration, or without having suppurated. In cases XXVII and XXVIII we have remark- able examples of this form of the disease proving fatal without sup- puration. In Case XXVII we can have little doubt that the disease had existed in the first 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 differ considerably from the other modifications of it. We have seen that it may con- tinue 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 continuing for some time in this state, pass into ramol- lissement or suppuration; but it appears, that in some cases it termi- nates 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 inflammatory 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 ofthe brain, from the surface downwards, or may be confined to a small circumscribed por- tion in the substance of the hemisphere. In this case, the affected portion appears, in some instances, to be afterwards surrounded by a cyst, and this appearance has been called a tumor in the brain. It is probable that it is merely a part of the cerebral 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 hope- less disease. In either of these states it may be fatal after protracted 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, Bur- serius 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 headache, and convulsive tremors of the whole body, which were most severe on the left side. He found another in the posterior part of the brain near the tentorium, in a woman who had been ill for several months with severe headache without fever: the pain was so intense as almost entirely to deprive REVIEW OF THE SUBJECT. 95 her of sleep, and she seems to have been gradually worn out by the severity of it without any other remarkable symptom. This form of chronic inflammation of a small part of the brain is a disease of much interest. The symptoms may go on for several months, so as to assume the character of organic disease ; they may remit, so as to resemble periodical headache ; the disease may be fatal with symptoms resembling apoplexy ; or it may pass into per- manent induration of the part affected ; or, after it has appeared to resist all our remedies, it may gradually subside. This agrees exactly with the course of chronic or scrofulous inflammation, as we observe it in external parts. We see it in the eye, in the lymphatic glands, in the testicle, in the mamma, and in the cellular texture. It takes place rapidly, producing enlargement of the parts, and derangement of the functions ; it may continue stationary for a considerable time ; it may then terminate by unhealthy suppuration or ulceration, or by permanent induration of the part'; or, after resisting for a long time all our remedies, it may gradually subside, without leaving any per- manent change in the organization of the part. I think there is little doubt that something of this kind takes place in the brain, and if this doctrine be admitted, the practical application of it will be, that we shall be less disposed than we usually are, to consider such cases as depending upon organic disease, and consequently not the objects of active treatment. The progress of this interesting affection is well illustrated by Case XXVII, and there are others on record which show it under some varieties in the symptoms. A gentleman, mentioned by Dr. Powell, was affected with severe headache, which occurred in par- oxysms: during the paroxysms, which often continued for several hours, he had double vision, mental depression, and at onetime mus- cular twitches and numbness of the left side. The pulse was variable, being sometimes a little frequent, and sometimes rather below the natural standard. By large and repeated bloodletting, &c. he was much relieved, but, after a short interval of relief, the complaint returned with great violence, and his vision remained permanently double. After several aggravations and remissions of this kind, he had, at the end of three weeks, an interval of ease for more than a fortnight. The pain then returned with violence, and was accom- panied 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 treat- ed 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 occurred at very uncertain intervals. They sometimes consisted of pain only, and sometimes of pain accompanied by the convulsive motions. He died suddenly in a convulsive attack, two months after the commencement of the 96 INFLAMMATION OF THE HEMISPHERES complaint; for some time he had been considered as better, and had sat up for two hours on the 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 tumor. When the dura mater was first removed, the part thus affected appeared to rise higher than the neighboring parts, and the cerebral substance sur rounding it was very soft. The morbid condition here described is probably a different stage of the disease which occurred in Cases XXXVII and XXXVIII; and there was a considerable similarity in ihe symptoms to the first attack in Case XXVIT. 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 suppura- tion, or without having suppurated; or, if it be seated in the superfi- cial parts ofthe brain, it may terminate by the ulceration of the sur- face formerly referred to. A man mentioned by Dr. Anderson, re- 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 some time 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 hemis- pheres 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 mater at that part was thickened and in- durated. A man, aged 45, mentioned by the same writer, had been liable for several years to convulsive paroxysms resembling epilepsy, but with 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 hemis- phere of the brain was found indurated, and closely adhering to the dura mater, which at that place was much thickened and hardened. Kxtravasated blood was found in another part ofthe head, which ap- peared 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, Morgagni found the anterior part of the right hemisphere of the brain indurated, and adhering to the dura mater. Baader relates the case of a man, aged 40, who became suddenly epileptic, with pain at a particular part ofthe left side of the head. There was exquisite 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 REVIEW OF THE SUBJECT. 97 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 ramollissement of suppuration; but that it also exists in a chronic form, in which its progress is very slow, so that it may produce urgent 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 induration of the cerebral substance, and may thus assume the characters of or- ganic disease. The disease may affect any part of the brain, and often appears to commence in a very small portion of it, and to ex- tend gradually over a larger portion. It appears to be in cases of this kind that we chiefly meet with some singular examples of gradual par- alysis, beginning perhaps in a very slight degree, or in a single muscle, and advancing very gradually to more perfect and more extensive pal- sy. A small part of the brain in such cases is probably undergoing this low state of inflammation, gradually gaining ground, and at length terminating either by fatal coma or permanent paralysis. In the palsy connected with these inflammatory affections, 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 feeling remains entire; and some remarkable examples are met with, in which the feeling is'morbidly increased. A case of this kind has been already referred to; another is mentioned by Lallemand. In this case there had been, after a blow on the head, headache, impaired intellect, and weakness ofthe limbs. Six weeks after, there was a sudden attack of loss of speech, with palsy ofthe right side, 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 ramollissement of the cerebral substance of the left side, and on the right side, extravasation of blood, which had obviously been the origin ofthe fatal attack. The disease occurs in the cerebellum in the same chronic 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. Douglass had been for three months affected with pain in the forehead, which ge- nerally obliged him to sit with his head leaning forward ; he had bad appetite and disturbed sleep, but no other symptoms. He died sud- denly in an attack resembling syncope, having been for a day much better, with good appetite and quiet sleep. An encysted abscess was found in the middle ofthe cerebellum, and a rupture ofthe left lateral 13 98 INFLAMMATION OF THE HEMISPHERES. sinus, which probably was the immediate cause of death.* A man, mentioned by Serries,f after a blow on the back and lateral part of the head, which stunned him at the time, had a 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 af fected 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 of the same side was numb and weakened. After the insertion of a seton in the neck, the arm recovered, and, three months after this, the patient died with fever, delirium, and an affection of the bowels. There was dis- ease in the right lobe of the cerebellum, with an abscess and exten- sive softening. In another man, mentioned by the same writer, who died in forty days, there was palsy of the right leg with wasting of the limb, but without loss of sensibility, the arm being little if at all affected. There was ramollissement of the left lobe of the cerebel- lum, occupying chiefly the centre of the left peduncle. SECTION VI. INFLAMMATION OF THE CENTRAL PARTS OF THE BRATN,--THE CORPUS CALLOSUM, SEPTUM LUCIDUM, FORNIX, AND THE MEM- BRANE LINING 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. In venturing to refer them to a place in the general arrangement ofthe inflammatory affections ofthe brain, I may perhaps be considered as advancing too rapidly to a con- clusion in regard to the pathology of this important class of diseases. But from all that I have observed of the affections themselves, and from the analogy ofthe corresponding diseases in other parts of the brain, I have now very little hesitation in arranging them in this man- ner. 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 propose the inquiry as one of much interest for farther observation. 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 lucidum, and corpus callosum. In the former case, we find the ventricles filled with a turbid or milky fluid, sometimes containing shreds of coagulable lymph, and sometimes having entirely the char- * Edin. Med. Ess. and observ. vol. vi. t Recherches Sur le Cervelet.—Journal de Physiologie, 1822—23. INFLAMMATION OF THE CENTRAL PARTS. 99 acters of purulent matter. These appearances are often combined with a deposition of flocculent matter or false membrane on the sur- face of the choroid plexus, or on the inner surface of the membrane lining the ventricles, and sometimes with ramollissement of the cere- bral matter immediately surrounding them. In the latter case, the affection presents itself in the form of ramollissement or white pulpy degeneration of the parts affected. The septum lucidum is found per- forated 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 irregu- lar 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 ofthe corpus callosum 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 effu- sion in the ventricles of limpid fluid. The substance which is the product of the disease, is of a pure white color, 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 seem to hold an important place in the pathology ofthe brain, and particularly in the pathology of acute hydrocephalus. A most interesting point in ihe history of it is, that it may be fatal without effusion, and with- out 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 perforation of the septum lu- cidum, surrounded by a ring of inflammation; I shall then show it as the only morbid appearance in cases which were fatal with the usual symptoms of acute disease in the brain; and finally, shall submit a se- lection of cases, showing its connexion with serous effusion in the va- rious forms of acute hydrocephalus. In regard to the pathology of this affection, I may also refer to the facts formerly adduced with re- spect to the ramollissement in other parts of the brain. Some of them seem to furnish the most satisfactory evidence of the inflammatory or- igin of this appearance, by enabling us to trace, in the same mass, one part in a state of inflammation, and another in a state of ramol- lissment, and the one distinctly passing into the other. I shall begin this part ofthe subject by an example of an affection, which seems to be rare,—inflammation confined to the membrane lining the ventricles. 100 INFLAMMATION OF THE CENTRAL PARTS. § I.--INFLAMMATION OF THE MEMBRANE LINING THE VENTRI- CLES. Case XLVI.—A child, aged 10 months (January 1819) had fe- ver, starting and vomiting; tongue white; bowels obstinate. Alter a week, the symptoms abated; his sleep became calm, and he was at times playful; but the vomiting continued, with frequent pulse. In this manner, he continued without any remarkable change in the symp- toms 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 pre- ceded by a slight convulsion. Inspection.—The ventricles were distended with six ounces of fluid, which was turbid, and contained in it flakes 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 ofthe cerebellum, the arachnoid, to the extent of a crown piece, was thickened and covered by ad- ventitious membrane; betwixt it and the pia mater at this place, there was some deposition of puriform matter. A case considerably similar to this in the morbid appearances, is related by Golis,* though the progress was much more rapid, and the smyptoms were more violent. A child, aged 14 months, after a rest- less night, was seized with violent fever and general convulsion, which subsided after topical bleeding, but soon returned with great violence, accompanied 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 ounces of turbid fluid; the inner surface ofthe ventricles and the surface ofthe choroid plexus were covered by adventitious membrane; and a similar de- position was found on the corpus callosum, and on the convolutions of the brain. The same appearance is mentioned by this author in sev- eral 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. Mor- gagni describes a case in an adult, in which the left ventricle was found full of purulent matter without any disease of the cerebral sub- stance. The characters of this case were fever, 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 ventricle, were distended with turbid fluid; their lining membrane thickened, and covered with a thick greenish-yellow matter and the fourth ventricle was full of pus. The patient was a man 41 * Golis on Hydrocephalus Acutus, Case II INFLAMMATION OF THE CENTRAL PARTS. 101 years of age, who, after complaining for five days of headache, lassi- tude andi mpaired digestion, was seized with fever, with increase of headache and vomiting, followed by drowsiuess, delirium, rigidity of the neck and dilated pupils, and he died comatose in six days. § II.--THE INFLAMMATORY ORIGIN OF THE RAMOLLISSEMENT 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, and for a fortnight she was better. She was then seized with severe pain of the belly, vomiting and headache, the bowels being rather obstinate. The pain of the head was violent, and chiefly referred to the fore- head. The pulse was from 30 to 40 in a minute, and there was a constant convulsive motion of the right arm and leg. Without any remarkable change in the symptoms, she sunk gradually into stupor, and died after two days of perfect coma, about a fortnight from the commencement of the headache. The convulsive motion of the right arm and leg continued through the whole course of the disease, and almost to the moment of death. The pulse continued from 30 to 40 in a minute until a few days before her death, when it rose to 70, and occasionally to 80. Inspection.—The ventricles of the brain were distended with col- orless fluid. In the septum lucidum, there was a ragged irregular opening from loss of substance, and the opening was surrounded by a ring of inflammation. The inner surface ofthe 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-colored and firmer than natural, and some small hard tubercles were imbedded in it. The inner surface ofthe caput coli and of the ascending colon was of a dark-red color, and large patches were elevated into a dark-red fungus. § III.--RAMOLLISSEMENT OF THE CENTRAL PARTS FATAL WITH- OUT 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 ofthe bed to the other, owing to the intensity of the pain; eyes slightly suffused, and impatient of light; pupils contracted; the pulse GO, soft and rather weak; tongue white. She was bled repeatedly, both generally and topically, and used purgatives, cold applications to the head, blistering, &c. For three days she appeared much re- 102 FATAL WITHOUT EFFUSION. lieved; 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 sen- sible 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 dis- tinctly; double vision; made no complaint, but said her head was bet- ter. 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 down into a soft white pulpy mass. There was no effusion in the ventri- cles, and no other disease in any part ofthe brain. Case XLIX.—A man, aged 36, a blacksmith, had been for some months affected 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 complain- ed of headache; and, after another day or two, a remarkable change was observed in his temper, which became uncommonly fretful and irascible. He still complained of constant headache, 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 head- ache. In the second week, he began to be slightly delirious, with a tendency to stupor: the headache continuing very severe. He be- came 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 ofthe body. Inspection.—The membranes of the brain were very vascular. 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 ofthe brain. The lungs were extensively tu- bercular, 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 of M. Senn,* the patient was eleven years of age. After some days of fever, with pain ofthe belly and vomit- ing, she complained of violent pain in the forehead, which was con- * Senn, Recherches sur-la Meningite Aigu' t* make room for the additional quantity, because the cavity is already completely full; and it is pro- 4^^^^S^^^^Ty ^Edinburgh, vol. i. Besides the O.N THE CIRCULATION IN THE BRAIN. 219 bable, that the quantity cannot be materially diminished, unless some- thing 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 de- gree 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 ofthe brain. But the blood circulating in these vessels must be divided in a cer- tain ratio betwixt the arteries and veins of the brain ; and it is pro- bable that the healthy state of this organ will depend upon the nice adjustment of the circulation in these two systems. If we could sup- pose a case in which more than the usual quantity of blood was ac- cumulated in the one system, the necessary effect would be a cor- responding dimunition 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 oc- cur in any other part of the body, because there is no other organ so situated as the brain. We must be cautious, however, of speculat- ing, where it is difficult to avoid falling into error, and must satisfy ourselves with attempting to trace, in a very general 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 par- take 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 actually take place, because the vessels of the brain are already full, the constant impulse will be such as tends to intro- duce an additional quantity, and consequently tends to derange the healthy relation betwixt the arterial and venous systems ; for any increase of quantity in the one system could not take place without a 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 circulation, 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 fol- lowed by a similar distention of the corresponding 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 ma^ 220 ON THE CIRCULATION IN THE BRAIN. 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 im- pulse, diminished to four, because the increased capacity7 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 con- tain and could transmit a quantity only as four. The quantity trans- mitted by the veins would then be the measure of the quantity that could enter the arteries from the general circulation, namely, a quan- tity as four. But the impulse from the general circulation would be such as tended to introduce a quantity as six, supposing the contin- uance of the undue impulse from which the disease originated, or a quantity as five, supposing the impulse to have subsided to the state of health. In either case the impulse would be such as tended to in- troduce a greater quantity than could enter, and consequently to keep up the deranged state of the cerebral 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, turgidi- ty of features, and other marks of increased determination to the ex- ternal parts. I am aware that this is hypothetical and conjectural; 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 can make towards a distinct conception of that condition to which we give the name of congestion 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 dimin- ished, there will be a corresponding diminution of the quantities which can enter the arteries. The healthy impulse from the general circulation will then become, in reference to the actual state of the circulation in the brain in this case, 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 preceding heads (1). If such a derangement, as has been supposed, 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 ON THE CIRCULATION IN THE BRAIN. 221 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 lake place in the apoplectic attack,—as the flushing of the face, turgidity of the features, throbbing of the external vessels, and 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 dis- sections, upwards of a pound was collected in this manner; and Dr. Kellie made the same observation on the two men whom he exam- ined 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 prepara- tion useless. The remarkable turgidity of the features and of the neck, which often occurs in apoplectic 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. Whyte, after some symptoms 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 color, and turgid in a most uncommon degree, but no turgidity was observed in the vessels of the brain. (2) Upon the grounds al- ready 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 evacuations will be to take off from the cerebral vessels, the excessive 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 favorable 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 produced 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 consider- able 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 enter the arteries of the head, but it would diminish in proportion to its extent the capacity of the veins, and thus derange the relations betwixt the two systems of vessels, in a different manner from that which has been supposed under 222 ON THE CIRCULATION IN THE BRAIN. the former heads, but analogous in its effects upon the circulation in the brain. When, in the former of the cases now supposed, the de- pressed portion of bone has been elevated, the two systems re- cover their healthy relations, and the symptoms disappear. It is probable that a cause of this kind may exist in a smaller de- gree, 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 impetus 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 pa- tient 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 gentleman, mentioned by Lancisi, who had lbng suffered from hemicrania, was seized about the age of 50 with intense pain in ihe temple, and soon after bad 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 autumn and winter, and he at last died suddenly in one of the attacks. Under the right side ofthe os frontis, the membranes were much thickened, and, con- nected with the thickened portion there was a kind of polypus on the surface of the brain. In cases such as these, it is probable, that, when the circulation is in a very tranquil state, or when the general mass of blood has been reduced by evacuations, the circulation in the brain goes on in a healthy manner; but that any increase ofthe quan- tity of the 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 (he sinuses, or of the prin- cipal veins of the brain; and 1 have formerly mentioned some re- markable cases, in which frequent attacks of an apoplectic and par- alytic 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 them. Minute attention to such cases may probably lead to results calculated to throw much light upon the pathology of apoplexy. IV. There are many interesting facts which lead us to believe, that the circulation in the brain may be deranged in a manner remark- ably 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 individual 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 general state of the system, so that the quantity of blood trans- ON THE CIRCULATION IN THE BRAIN. 223 initted.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 corres- pondingly diminished and inadequate impetus. It is probably in this manner that there arises the appearance of congestion in the superfi- cial veins of the brain, which has 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 circulation 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 con- siderable quantities of blood by arterial haemorrhage from the rectum. Considering it as merely haemorrhoidal, he had paid little attention to it, until his friends became alarmed by his altered appearance. From being strong and rather plethoric, he had become weak, exhausted, pale and haggard. He had anarsarca of his legs,—his pulse was fre- quent 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 throb- bing in the head, and frequently of throbbing headache. On exam- ing his rectum, a fungous tumor was found within the sphincter, on the apex of which a small artery was bleeding per saltum. This was tied, and there was no return ofthe haemorrhage; and under the use of nourishing diet, and a liberal allowance of wine, all his other complaints disappeared. He made up so rapidly in flesh and blood, that notlong after, apprehensions were entertained that he was becoming too pleth- oric, and it became necessary to reduce his regimen, but under these circumstances he had no return ofthe symptoms in his head. A lady, aged twenty-five, had been frequently bled on account of symptoms in the head which had supervened upon an injury. Con- siderable relief had followed each bleeding; but the symptoms had soon returned so as to lead to a repetition of the bleeding at short in- tervals, and this had been going on for several months. When I saw her, she was stretched upon a couch, her face of the most deathlike paleness, or rather ofthe paleness of a strucco 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 complained of frequent headache, violent throbbing in the head, confusion, and giddiness. It was evi- dent 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 system, nour- ishing diet and tonics, In a fortnight she was restored to very toler- able health. Under similar circumstances a friend of mine was called to visit a 224 ON THE CIRCULATION IN THE STRAIN. lady who had suffered from long-continued uterine haemorrhage. Her general aspect was that of great exhaustion, but she complained so much of throbbing in the head, that her medical attendants were treat- ing 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 circumstances. A gentleman accustomed to very full living, is seized with an apoplec- tic attack, or with symptoms indicating the most urgent danger of ap- oplexy; he is saved by bleeding and other free evacuations, and is kept for some time upon a very spare diet. His complaints are re- lieved, 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 in- dicates the very reverse of plethora; and these symptoms are removed by a cautious improvement of his regimen. This curious fact I have repeatedly had occasion to attend to in the treatment of cases of this kind, and it has always appeared to me to be one of very great inter- est in reference to the pathology of the brain. Various other facts will present themselves to the practical physi- cian, which bear upon this curious subject. In the last stage of dis- eases of exhaustion, patients frequently fall into a state resembling co- ma, 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 ofthe brain. It attacks them after some continuance of exhausting diseases, such as tedious and neglected diarrhoea; and the patients lie in a state of insensibility, 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 favor- ably, or it may be fatal. This affection appears to correspond with the apoplexia ex inanitione of the older writers. It differs from syn- cope 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 exhaustion, in the com- plete abolition of sense and motion, while the pulse can be felt dis- tinctly, 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 neglected diarrhoea, fell into a state closely resembling coma; his face pale and collapsed, but his pulse of tolerable strength. An el- derly lady from the same cause, had loss of memory and squinting. Both these cases recovered by wine and opiates; in the former, blis- ON THE CIRCULATION IN THE BRAIN. 225 tering on the neck was also employed. Richter states that amaurosis has been produced by hemorrhage, cholera, and tedious diarrhoea; and he mentions particularly a dropsical woman, who became blind when the fluid was evacuated from her abdomen by tapping. On this inter- esting subject, I shall at present only add the following remarkable illustration from an affection of hearing. A gentleman, about 30 years of age, came to Edinburgh from a distance for advice in regard to an obscure affection, referred chiefly to the stomach, which had re- duced him to a state of extreme weakness and emaciation. As the debility had advanced, 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 horizontally, 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 himself again into the erect posture, he continued to hear distinctly 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 impeded 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 remarkable similarity in the symptoms which occur in these oppo- site conditions. What indeed is syncope, but an abolition of sense and motion ? It is preceded by giddiness, tinnitus aurium, and im- paired 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 cir- culation, the symptoms accompanying the two affections being re- markably 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 so peculiarly balanced, why is it not seriously deranged by the numerous changes which are constantly occurring amid the variety of circumstances to which the body is exposed? Why is not apoplexy produced by every increase in the mass of blood, or why is it not excited 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 occur- rence, though in a certain condition ofthe 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 con- tinued canals of bone. These appear to have considerable influence in arresting any sudden impulse of blood, and in directing it off to the 29 226 ON THE CIRCULATION IN THE BRAIN. external branches. Hence the flushing of the face, turgidity of the features, and throbbing ofthe external vessels, which often occur in such cases, while no affection in the brain follows. Another circum- stance, which seems to contribute to the same purpose, is the pecu- liar structure of the sinuses of the dura mater. These at all times must contain a considerable proportion ofthe venous blood of the brain, and from their peculiar structure it seems probable that they are not liable to have their area either increased of diminished in any considerable degree. This remarkable structure must operate very considerably in preventing those derangements of the circulation which have been referred to in the preceding speculations, and which, in an organ situated as the brain is, must otherwise have taken place from very slight causes. PART 111. OF THE ORGANIC DISEASES OF THE BRAIN. By organic diseases ofthe brain we understand, either permanent changes of the cerebral substance itself, or new formations within the head. These may be either embedded in the substance ofthe 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 thickening of the membranes of the brain, or by deposition of new matter betwixt their laminae. Of this I have already given a very remarkable example, (Case VI.) in which a tumor five inches long, three inches broad, and half an inch in thick- ness, was formed in this manner by a deposition of new matter be- twixt the laminae of the dura mater. II. Deposition of a pellucid or semi-pellucid substance having the characters of albumen. This may either be formed in undefined masses under the membranes of the brain, particularly under the arachnoid, as in Case XCII, or contained in distinct cysts in vari- ous parts of the brain, as in the Cases XC and XCL 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 consis- tency, and there is some reason to believe that it undergoes remarka- ble changes in density, assuming a firmer texture in certain stages of its progress. III. A very dense tumor, of a uniform whitish or ash color, and exhibiting the appearance and the properties of coagulated albumen. This substance is found in distinct rounded tumors of various sizes, which are generally attached to the dura mater, and do not appear to be covered by any cyst. 1 have described one which grew on the falx in Case LXXXVII, nearly five inches in circumference, and uniformly white and firm in its consistence; it did not appear to be organised, and when analyzed exhibited the properties of coagulated albumen. The remarkable cilcumstance 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 228 ORGANIC DISEASES OF THE BRAIN. external surface of the dura mater; in this case fhey have been fre- quently known to produce absorption of the bone, and to rise exter- nally 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 disease 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 ventricle, the size of small hazel-nuts, in a man who died suddenly after having had repeated epi- leptic attacks at long intervals, and having been for some time affect- ed with symptoms threatnening apoplexy. IV. Tumors externally resembling those of the former class, but internally presenting an organised appearance, and a reddish or flesh- color, resembling the substance of the kidney. These are met with in various situations; one will be described, 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 ap- pear to be more uncommon. 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 mem- branes. In their earlier stages, they present to us a whitish-colored cheesy matter, generally enclosed in a cyst; but, in their more ad- vanced forms, we generally find them presenting a greater or less de- gree of unhealthy scrofulous suppuration. VI. Induration of the cerebral substance. Several examples of this important affection have been already7 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 action; that it may continue for a 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 coagulable lymph, giving it the appearance of a new formation em- bedded in the substance of the brain. In the state of simple indura- tion, this disease may continue for a long time, producing urgent symptoms, and may at length be fatal by passing into suppuration, or without having suppurated. VII. Ossifications. Under this head are.to be included both osse- ous projections from the inner surface of the cranium, and internal ossifications, which are commonly found in the dura mater, and most commonly in the falx. They generally appear to be formed of thin ORGANIC DISEASES OF THE BRAIN. 229 laminae of bone in ihe 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 pro- duce urgent symptoms, 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 discharged 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 thes ubstance of the cerebellum. VIII. Hydatids. This name has been applied to several affections ofthe 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 cellular texture of that organ, elevat- ed 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 brain; but k 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 head- ache for a year with constant vertigo, and then died apoplectic. In the substance ofthe left hemisphere, there was a cyst the size of an egg, which contained a clear fluid. In a girl mentioned by the same writer, who died, on the 12th day, of a febrile disease, which ended in coma, there was found, on seperating the two hemispheres, 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 discharged 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 bad really been contained in the ventricles, until I received, through my friend Dr. Frampton, the re- markable case by Mr. Headington, to be afterwards described, m which a cyst was found in the left ventricle containing sixteen ounces ° The affections now briefly described seem to include the principal modifications of the organic disease 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 Schenk.us, the bloody tumor of Rochoux, and the real fungus hamialodes of the brain, of which there are some examples on record. Fungous protrusion of the ce- rebral substance itself, such as occurs after the operation of the tre- 230 ORGANIC DISEASES OF THE BRAIN. phine, is occasionally met without any such cause. A man mentioned by Dr. Donald Monro, had a pulsating tumor over the left eyebyrow, pressure on which produced headache and giddiness. It increased in size, and after seven months he died lethargic. On inspection the tu- mor 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 medullary substance ofthe brain; and it appeared to be covered by the dura ma- ter.* When we endeavor to trace the leading symptoms connected with these various states of disease, we do not find any uniformity, by which particular symptoms can be distincly referred to the various forms of the morbid affections; we can therefore attempt only a very general outline ofthe principal modifications of the symptoms, which are con- nected with organic disease ofthe brain. They appear to be chiefly referable to the following heads. 1. The first class is distinguished by long-continued and severe headache, without any other remarkable symptom. The pain varies very much both in its seat and in its severity; and one very remarka- ble 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 sometimes referred to a particular spot, as the crown of the head, or the occiput. In many cases it is accompanied by a violent throb- bing, and this also may be general, or it may be referred to a particu- lar part of the head, as the occiput or one temple. In the more vio- lent 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 remission from this severe suffering are often so remarkable as to lead a superficial observer into the belief that it is merely periodical headache, or headache connected with dis- pepsia. This latter supposition is also countenanced by the stomach being frequently much disordered, and by the more violent attacks 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 headache, and that, though the stom- ache is at times disordered, yet that, the headache is often most se- vere when no disorder exists in the stomach that can account for it. The patient generally cannot bear a warm room, the noise of com- pany, or even the exertion of cheerful conversation, without being dis- » Trans. Col. Phy. vol. i, ORGANIC DISEASES OF THE BRAIN. 231 tressed and his headache increased; and the same effects are pro- duced by wine and bodily exertion. He seeks quietness, coolness, and darkness; and in these respects, the disease differs remarkably from dyspeptic headache, which is commonly dissipated by exercise and cheerful company. Sometimes the paroxysms are accompanied by vomiting, and sometimes 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 frequent termination is by the accession of chronic inflammation, terminating by effbsion 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 symptoms of chronic inflammation a few weeks before death. II. In the second form, after some continuance of fixed headache, the organs of sense become affected, as the sight, the hearing, the taste and smell, and occasionally the intellect. The loss of sight gen- erally 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 lime, sight was restored under the action of an emet- ic. It remained distinct for an hour, and then was permanently lost. The intellect is frequently impaired in cases of this class, and some- times the speech is lost. The morbid appearances present no unifor- ity; in two of them there were tumors so situated, as directly to com- press the optic nerves; in another, a large tumor pressed upon the corpora quadrigemina; in a third, the disease was situated at the low- er part of the anterior lobe; and in another, 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 disease was an enlarge- ment ofthe pineal gland; and in another, in which there were both blindness and deafness, a large tumor was situated between the brain and the cerebellum. Ill The third class corresponds with the second in the pain and affections of the senses, with the addition of paroxysms 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 azcrravated, and to be combined with some degree of inflammatory ac- tion. Sometimes the paroxysms have a resemblance to tetanus, and n other to slight apoplectic attacks. A case of this kind will be refer- 232 ORGANIC DISEASES OF THE BRAIN. red 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 appear- ance 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 inva- riably to produce blindness; but, in other cases, it will appear that tu- mors corresponding in their situation, and nearly of similar size, were in some cases accompanied with blindness and convulsion; 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 re- markable" from the circumstance, that the convulsions ceased when the lungs became affected, and did not return, the affection ofthe lungs being fatal. IV. The fourth class is distinguished by convulsion, without any affection ofthe 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 under the regular form of epilepsy; in others, in more irregular attacks, occurring re- peatedly for a short time, and then ceasing for a considerable interval. Sometimes violent paroxysms of headache 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 convul- sion, or by coma of some days continuance. The morbid appearan- ces are very various. The most remarkable in the cases to be refer- red to were, tubercules in the cerebellum, and hydatid in the right hemisphere ofthe brain, induration of pons Varolii or ofthe substance ofthe brain, and tumors and bony spiculae in various situations. An important 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 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 symptoms namely, the paralytic. These may occur in the form of hemiplegia' paraplegia, or paralysis of all the parts below the neck, and in some cases one limb only is affected. The disease is distin- guished from the ordinary paralync cases, by coming on more gradu- ally; 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 preceded by violent pain in the limb The speech is generally affected, and in many cases the memory; there ORGANIC DISEASES OF THE BRAIN. S33 may be fixed uneasiness in the head, or headache occurring in parox- ysms. In one case, there was blindness of one eye; in another, of both. In one, there occurred convulsion, but not till an advanced period; in another, epilepsy for more than a year. The inspections exhibit tumors or indurations, variously situated; in the cases of hem- iplegia, on the opposite side of the brain; in those of paraplegia, in the cerebellum or tuber annulare. It must, however, be confessed, that the cases of this class, with paraplegia, are rather unsatisfactory from want of attention to the condition ofthe 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 inter- est; a train of symptoms which are referred to the stomach, but which really depend upon disease in the brain. In many of the cases of or- ganic 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 symptom. In these there is often, through a consider- able part of their progress, very little complaint of the head, or no complaint 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 paroxysms like periodical headache, or in paroxysms accompanied by vomiting, like what is commonly called sick headache. The pain is increased by exertions, external heat, passions of the mind, and stimulating liquors; there is generally variable appetite, bad sleep, oppression of the stomach, and frequent vomiting. The vomiting sometimes occurs in the morning, on first awaking, and sometimes at uncertain intervals, and very sud- denly without any previous sickness. There are, in general, uneasy sensations referred to various organs, by which the nature of the dis- ease may be disguised in its earlier periods; 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 suffering. In cases of this class, we must beware of being misled in regard to the nature of the complaint, by observing that the symptoms in the stomach are alleviated by a strict regimen, or by treatment directed to the stomach itself. If digestion be impeded from whatever cause, the uneasy symptoms may in this manner be alleviated; but no infer- ence can be drawn from this fact, in regard to the cause of the de- rangement. In the earlier periods of this affection, the diagnosis is indeed often very difficult. There is generally more permanent and fixed uneasiness in the head, than we should expect to find in a dys- 30 234 ORGANIC DISEASES OF THE BRAIN. peptic case, and the uneasiness is increased by causes which would probably be beneficial to a dyspeptic headache, such as activity and cheerful company. The prominent morbid appearances in cases of this class" seem to be in the cerebellum. VII. The seventh class is distinguished chiefly by slight and tran- sient 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 with- out loss of recollection, which are soon recovered from. Sometimes there are attacks of perfect coma, which may occur at regular or at irregular intervals; the patient having, in some cases, such warning of their approach that he goes to bed before the attack. There is usu- ally more or less unsteadiness of the limbs, and generally, but not al- ways, headache. In some cases there are affections of sight, and these may either be permanent or occur in paroxysms; arid in some cases, giddiness and loss of recollection are excited by bodily exer- tion, and go off on desisting from it. This imperfect outline of a most important class of diseases, I shall illustrate by a selection of cases in an Appendix, partly from my own observation, and partly7 from other authorities. From these will ap- pear the extreme difficulty of fixing upon any general principles, or of referring the particular character of the symptoms to any thing in the seat or nature of the disease. Tumors, for example, will be found under the first class, unaccompanied by any remarkable symptoms; while, under the other classes, tumors in the same situation, and of no larger size, were accompanied by blindness, convulsions, or paralysis. It does not appear that these diversities 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 diversity of symptoms is connected with the nature of the tu- mors, and especially with their characters, as being tumors distinct from the cerebral mass, or as being indurations of the substance ofthe 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 treatment, 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 evacuations and spare diet, cold applications to the head, issues or setons in the neck, and avoiding all causes of excitement. I conclude this part of the subject with the following important ORGANIC DISEASES OF THE BRAIN. 235 case, which I received from my friend the late Dr. Kellie of Leith. It illustrates, in a very striking manner, 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 cultivated mind and temperate habits, had been for some time liable to various ailments, which his medical friends considered as in a great measure hypochondriacal. The most defined complaints were occasional un- easiness 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 headache, and an obvious difficulty of articulation, or rather a diffi- culty in finding the expression which he wished to make use of. He was now treated by bleeding and the other usual means; but this pe- culiar loss of the recollection of words continued and gradually in- creased, so that he had greater and greater difficulty in recollecting the words which he meant to employ, but he had no difficulty in pro- nouncing 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 increased to perfect hemiplegia; and about this time, also, he entirely lost his speech. He was now7 confined to bed, but without coma. He had the perfect use of his sight and hearing, 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 ofthe brain was found to be dis- eased throughout in a very singular manner. Some parts of the mass were indurated, others softened; and it presented a variety of colors, chiefly a rose-color, grey, and yellow; and the more diseased por- tions were highly vascular. In some places there were distinct insu- lated masses, enclosed in vascular cysts; these were generally indu- rated, but some were softened, and they were of a rose or flesh-color passing into grey. The change from those parts which retained a natural appearance to these degenerated portions was abrupt, and marked by a rose-colored line. These rose-colored portions were chiefly in the parts nearest the surface; in the central parts this passed into the yellow or the grey, and many portions were in a state of ramollissement. The whole left hemisphere, in fact, presented little else than a mass of concentric indurations and softenings of the various colors which have been mentioned. On the upper part of the 236 ORGANIC DISEASES OF THE BRAIN. hemisphere, the disease did not extend entirely to the surface of the convolutions; but at the base of the anterior and middle lobes it ex- tended 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 analogous 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 cellular texture, scarcely deserving a distinct name, it will answer every practical purpose to consider the mem- branes as two. I. The dura mater of the cord does not differ in structure from that of the brain, except in varying considerably in thickness at differ- ent 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 foramen magnum. In this manner a cavity is pro- duced betwixt the membrane and the canal of the spine, which may be the seat of effusion, and which has no communication with the cav- ity of the cranium; on the other hand, the space betwixt the dura mater and the pia mater, or the immediate covering of the cord, com- municates freely with the cavity of the cranium, so that a fluid may pass easily from one to the other, according to the position of the body. II. The pia mater, or proper covering of the cord, is a membrane of a loose or cellular texture. It seems to be continuous from the pia mater ofthe brain, is closely attached to the 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 distinguished into cortical and medullary matter. It is divided into four columns, the two anterior of which take their origin from the crura cerebri, and the two poste- rior from the crura cerebelli. The spinal nerves arise by two distinct roots from one of the anterior, and one of the posterior of these col- 338 DISEASES OF THE SPINAL CORD. umns; and recent investigations have rendered it probable, that a di- versity of function is concerned in the double origin, that is, that the posterior columns give origin to the nerves of sensation, and the an- terior to the nerves of motion. A canal has been described in the substance ofthe cord, which is said to be a seat of serous effusion, and to communicate with the fourth ventricle. On the authority of Portal, 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 slate of the parts. In Portal's case, it extended as far as the fourth dorsal vertebra, 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 spinal cord in convulsive and paralytic affections, but their speculations 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 ofthe best authenticated facts, which may be arranged under the following heads: I. iAcute inflammation of the membranes, or meningitis of the cord. II. Inflammation of the body ofthe cord, terminating by ramollisse- ment 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 ofthe membranes. VI. Induration of the cord. VII. Compression of the cord by new formations within the canal, as tubercles, albuminous depositions, hydatids, and ossification of the membranes. VIII. Destruction of a portion ofthe cord. IX. Concussion of the spinal cord. X. Certain affections ofthe bones ofthe 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 pre- sent at the examination of the body. I shall merely relate the cases, MENINGITIS OF THE CORD. 239 without founding upon them any general conclusions in regard to the characters of the disease. Case CXLI.—A gentleman, aged 26, had been for several years liable to suppuration of the left ear. It usually discharged at all times a little maiter, 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 headache, which affected both the fore- head and the occiput ; he lay in bed only part of the day ; his ap- petite was bad, and his sleep disturbed ; but there was little or no frequency of pulse, and for a week the complaint excited little at- tention. xVbout the end ofthe week, he complained of pain extend- ing 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 se- vere, and extended farther downwards along the spine. It continu- ed for several days to extend farther and farther down, until at last it fixed with intense severity at the lower part of the spine, and ex- tended from thence round the body, towards the spinous processes of the ilia. From this time he never complained of his head, and sel- dom of the upper parts of the spine ; but he became affected with great uneasiness over the whole abdomen, and great pain and difficul- ty in passing his urine. From the violence of these complaints, his sufferings about the 15th became extreme ; he could not lie in bed for five minutes at a time, but was generally walking about the house in a slate of extreme agitation, grasping the lower part of his back with both his hands, and gnashing his teeth from the intensity of pain; he had no interval of ease, and was sometimes incoherent and unman- ageable. On the 16th, he went to the warm bath, walking down three stairs, and into an adjoining street, with little assistance. 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 dysuria, confusion of thought, and some dif- ficulty 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 swallow- ing; some squinting also was observed, but it was not permanent; the pulse was from 120 to 130. At night he became 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 un- manageable. About three o'clock, while sitting in a chair, he sud- denly 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 S40 MENINGITIS OF THE CORD. the disease, except the slight affection of his speech, no difficulty 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 dis- charged 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 taking out the brain, some gelatinous deposition was found under the medulla oblongata, and purulent matter appeared in considerable quantity, flowing from the spinal canal. The spine being entirely laid open, the cord was found with a coating of purulent matter, which lay be- twixt it and its membranes. The matter was most abundant at three places ; at the upper part near the foramen magnum, about the mid- dle of the dorsal region, and at the top of the sacrum ; but it was also distributed over the other parts with much uniformity. The substance of the cord was very soft, and in some places much divid- ed 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, extending over every part ofthe 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 ofthe right scapula; also of an acute pain in the right hy- pogastric region, increased by pressure and by inspiration. The head was considerably retracted, and could not be bent forward; the spine was bent backwards, and the muscles of the back felt contracted and rigid. She had alternate rigors and flushes of heat, great restless- ness; pulse 148 and full; respiration 44, with some cough; tongue foul; bowels confined. She was treated 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 seemed somewhat relieved, and could bring her head a little forward; 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 distended and tense. She had less dif- ficulty of swallowing, and vvas inclined to sleep, but during sleep there was much subsultus; 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- MENINGITIS OF THE CORD. 241 sultus and tremor; pulse 1-10; 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 ofthe neck became entirely relaxed. Inspection.—There was some fluid in the ventricles of the brain; and, on the posterior edge of the right lobe of the cerebellum, there was a thread of coagulable lymph. The cervical portion of the spi- nal cord was healthy; the dorsal and lumbar portions were covered by a uniform thin coating of coagulable lymph of a greenish-yellow color, and soft consistence. It was chiefly on the posterior part, be- twixt the cord and its membranes, and the membranes were remarka- bly vascular. Several cases have been described by Duchatelet and Martinet, of inflammation of the membranes of the cord terminating by puri- form deposition, but they were in general complicated 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 muscles 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. Olliver, in his second edition, has described several interesting cases, which present the same general characters. The prominent symptom was, pain referred to some part ofthe spine increased by motion, and sometimes little complained of except upon motion ; it in general extended along some ofthe 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 re- missions 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. After seven- teen days this ceased, and vvas succeeded by pain in the loins, which afterwards extended along the back and into the inferior extremities; and was then accompanied by muscular 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, lhere was extensive deposition of pus and false membrane between the mem- branes 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 symptoms 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 feeling. There were afterwards ng.d.ty 242 MENINGITIS OF THE CORD. and partial paralysis ofthe arms, rigidity ofthe 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 flocculent 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 softening ofthe substance of the cord.* To these examples of this remarkable disease, I shall only add a case mentioned by7 Andral. A woman aged 28, after sudden cessa- tion of the menstrual discharge, induced by mental agitation, had fever, hysterical symptoms and vomiting; about the fifth day she had retrac- tion ofthe head, with severe pain extending along the whole course of the spine; it was not affected by pressure, but was increased to ex- treme agony by the least motion. She had afterwards difficult breath- ing and tetanic symptoms, followed by dglirum 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 contained chiefly in the cellu- lur texture of the arachnoid ofthe cord. The membranes ofthe brain were deeply injected; there was membranous deposition on some parts, especially on the right side, also on the tentorium and below the cerebellum,—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 waggoner, 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 ofthe neck; he could move all his limbs with freedom. On the 8th day after his admission, he was seized with general convulsions and locked jaw. After a few hours, he was affected with a singular convulsive 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 perfectly sensible, and had recovered sensation in his legs." On dissection, a great quantity of purulent matter was found within the spinal canal, which had dropped down to the lower part of it. It appeared to have been formed about the last cervical and first dorsal vertebra?, and at that place the intervertebral cartilage was destroyed, so that the pus had escaped outwards among the muscles. In another case related " Ollivier, Traite de la Moelle Epinicre et ses Maladies. Tome ii. 2d edit. MENINGITIS OF THE CORD. 243 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 leading symptoms were fe- ver, restlessness, vomiting, and high delirium; death took place from sudden sinking.' To this place, perhaps, should be referred some notice of the ap- pearance of increased vascularity of the cord or its membranes, and turgidity of vessels about the origin of the nerves. It constitutes the plethora spinalis of continental writers; and much importance has been attached to it as the cause of disease in many of the principal functions of the body. By exciting irritation at the origin of the va- rious spinal nerves, it has been considered as the source of many ob- scure affections of the thorax and abdomen; of tremor, convulsions, paralytic affections, chorea, epilepsy, and tetanus. It has also been regarded as the seat of many of those painful affections of the back and the loins, which take place in connexion with haemorrhoids, men- struation, abortion, and continued fever. These writers have specu- lated much on the changes which take place in the thoracic and ab- dominal 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 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 writers 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 ex- tremities. On dissection, the arteries of that part of the spinal cord, which is included in the dorsal vertebrae, were found turgid with blood, as if they had been highly injected.}: Portal refers to several other cases, which he explains upon the same principle, and in which con- vulsive and paralytic affections of the extremities occurred in various inflammatory diseases. (2.) An infant was attacked during dentition with convulsions, which degenerated into epileptic fits. When he was five years and £ 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 inject- ed, and the medullary substance was softened and of yellowish color about the 6th and 12th dorsal vertebrae.§ (3.) A young man, aged twenty-one, was affected with fever and * Quarterly Reports of Cases of Surgery, part 2. . t See Frank, Oratio de Vertebralis Columnar in morbis dignitate, Brera della Rach- ialgite, and Ludwig de Dolore ad Spinam Dorsi. | Portal, Cours d' Anatomie Medicale, torn. in. page il» § Esquirol Bulletin de la Faculte de Medecine, 244 INFLAMMATION OF THE SPINAL CORD. high delirium. When the delirium subsided, he had convulsive mo- tions of the superior extremities, and soon after died comatose. On dissection, the vessels ofthe pia mater ofthe 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 ori- gin of some of the spinal nerves. There vvas a similar appearance on the pia mater ofthe brain, and some effusion on its surface.* SECTION II. INFLAMMATION OF THE SUBSTANCE OF THE SPINAL CORD. In referring to inflammation ofthe substance ofthe cord, the appear- ances to be described under this section, I am guided by the analogy of the corresponding affections of the brain. I allude more particu- larly to the ramollissement, which seems to be one of the most com- mon 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 inflammation. I again leave this doctrine, however, to the judgment 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 rea- son to believe, that inflammation of the substance of the cord, like the corresponding affection of the brain, may terminate fatally in four dif- ferent forms: I. In the inflammatory stage. II. By ramollissement. III. By undefined suppuration. IV. By abscess. § I.—Inflammation of the substance of the cord fatal in THE INFLAMMATORY STAGE WITH INCIPIENT RAMOLLISSEMENT. This part of the subject is obscure, and the termination of the dis- ease in the inflammatory stage may perhaps be considered as not as- certained. 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 men- ses; this occurred at every period; when the discharge took place freely, it ceased. After the cessation of the menses, which happened * Morgagni, Ep. x. RAMOLLISSEMENT OF THE CORD. 245 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 co- matose. On dissection, the membranes ofthe spinal cord were found in a state of inflammation at some of the last dorsal vertebras. 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 de- scribed by Laelius a Fonte, in which death happened on the 14th day of continued fever, after paraplegia and suppression of urine; " in con- spectum venit ren sinister, inflammatuset syderatus; laesa etiam erat medulla spinalis in eodem latere." § II.—Ramollissement of the cord. This remarkable affection will be illustrated by the following impor- tant cases. In the first it was complicated with extensive inflamma- tion of the membranes; the second shows the disease confined to the body ofthe cord; and the third is chiefly remarkable from its resem- blance in the symptoms to an affection of the brain. The fourth shows the affection arising from an injury; and the fifth affords a very inter- esting example ofthe disease in a chronic form. Case CXLIII.—A gentleman, aged 18, of an unhealthy constitu- tion, had suffered for several years from ulcers in various 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 upwards. 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 account 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 confined to the house, and complained of pain in his loins without fever. On the 2d of October, this pain had in- creased; it was chiefly seated among the lower dorsal vertebrae, and extended 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 fever; 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 complained of pain ofthe 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 cattfeter. (6th,) The numbness of the thighs was increased, with acute dart- * Portal, Cours d' Anatomie Medicale, tome iv. page 116. 246 ramollissement of the cord. ing 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 ofthe dorsal region; there was no other symptom. Cup- ping on the back was employed, followed by another large blis- ter, &c. (9th, 10th, and 11th,) There was no change, except that the pulse was becoming a little frequent. His mind was entire. Some pain of the back was at times mentioned, but it was not severe, and he made no other complaint. Perfect palsy ofthe limbs continued, and the numbness was extending 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 com- plained 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 con- sequence of this appearance, a perforation was made by a small head of a trephine, but no disease was found beneath the bone. In the evening, his pulse having become more frequent, farther bleeding 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 extremities, 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 thickened, especially on one side, where it was fully double the natural thickness. There was no effu- sion in the head, and no appearance of any recent disease. In opening the spinal canal some purulent matter flowed out during the sawing, from about the middle of the dorsal region; and one of the vertebrae at that place was found considerable carious. The canal be- ing 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 cer- vical vertebra. The dura mater of the cord being laid -open, bloody sanious fluid was discharged from beneath it; and the pia mater was RAMOLLISSEMENT OF THE CORD. 247 found highly vascular. The substance of the cord was found most extensively destroyed in ils structure 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 poste- rior part, the cord was more entire. When the whole cord was taken out and suspended, it hung together by the posterior columns ofthe dorsal portion, while the anterior part of it fell off entirely in a soft diffluent state. The parts above and below the diseased portion were quite firm and healthy. Case CXL1V.—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 headache. 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 commencement of the disease, the whole leg and arm had become completely paralytic. Some pain con- tinued 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 complain- ed of some headache, and of pain extending from the shoulder along the affected arm atid leg. Repeated bloodletting, blistering, purga- tives, &c, were employed, and the headache was removed. The other symptoms continued as before; the right leg and arm were com- pletely paralytic, and sometimes very painful; pulse 84, and rather weak; his mind quite entire. He continued in this state till about the 26th of April, when the left arm became paralytic rather suddenly; it did not however 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 exhaustion. I saw him first about this time. There was slight delirium, which how- ever passed off again; and he continued quite sensible and even cheer- ful, 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 ra- 248 RAMOLLISSEMENT OF THE CORD. mollissement, 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 headache and slight feverishness, for which he took purgative medicine, and on the morning of the 22d he seemed almost well. About two o'clock in the afternoon of that day, he was seized w7ith severe and general 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 became less comatose, but incoherent, with much talking-and screaming; complained of head- ache, and was impatient of light. In the evening there was slight ap- pearance of squinting, 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 sensible, and said there was still some headache, but did not appear to suffer; he con- tinued in this favorable state until early 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 mem- brane. The cord was healthy at the cervical portion, but in the up- per 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 attempt- ing to raise the cord, the part falling down into a soft diffluent pulp through its whole diameter. From the middle ofthe dorsal portion it was quite firm and healthy. The inner membrane of the cord was dark-colored, highly vascular, and showed evident marks of inflam- mation, at the part corresponding with the softened portion of the cord. The following case (for which [ am indebted to Dr. Hunter) shows this affection arising from an external injury, without any af- fection of the bones of the spine. R0M0LLISSEMKNT OF THK CORD. 249 Case CXLV I.—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 complete 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 lo 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 considera- bly emaciated, and • there was complete loss of motion of the lower extremities, without loss of feeling, and all the muscles of the affected parts were in a remarkable 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 obstructed, apparent- ly from the viscidity ofthe mucus impeding^ the passage, and he then required the catheter. His breathing was very slow, being general- ly, when he was asleep, about nine in a minute; and when awake about thirteen. His pidse and other functions were natural; his up- petite was moderate, and his digestion good; his mind was quite en- tire. On the third day after his admission, he began to complain of pain in the temporal and. masseter muscles, with inability lo open the jaw; and this rapidly increased to perfect trismus. He then had emprosthotonos, and the usual tetanic symptoms; the abdominal mus- cles being very tense and bard, and the body considerably bent for- ward. On the following day more general spasms took place, affec- ting the arms and face, and the muscles about the neck and throat, with great difficulty of swallowing. The spasms now assumed the form of opisthotones. 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 without ben- efit. , Inspection.—No i njury could be detected in any of the bones of the spine. There vvas a high degree of vascularity of the pia mater of the cord, especially at the upper part ofthe dorsal region. There was most extensive ramollissement of the body of the cord, which af- fected 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 up- per part of the cord, and affected the corpora pyrmidaha. The pos- terior columns were also softened in many places, though in a much smaller degree, not diffluent like the anterior, but breaking down un- der very slight pressure. 32 250 RAMOLLISSEMENT OF THE CORD. A remarkable modification of the disease occurs, in which, al- though it is seated in the upper part of the cord, the symptoms ap- pear only in the superior extremities and adjoining organs, without any affection of the lower parts of the body. A gentleman men- tioned by Ollivier, who vvas liable to epilepsy, complained first of uneasiness in the throat, with difficulty of swallowing, accompanied by an acute pain in the nape of the neck, and lower part of the occi- put, 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 man- ner, and on the following day they were both paralytic. His legs were not in the least affected, nor the functions ofthe bladder or the bowels. There was at last increase of dyspnoea with extreme diffi- culty 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 extensive ramollissement of the upper part of the cord, chiefly seated in the grey7 matter, which was of a rose-color, 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 vascularity of the bronchial membrane. In an- other case, with extensive ramollissement at the upper part of the cervical portion, there was palsy of all the extremities. The only difference 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 de- gree, 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 affected 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. This form will be illustrated by the follovying case, which I saw along with Dr. Alison. Case CXLVII.—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 RAMOLLISSEMENT OF THE CORD. 251 a short time this was succeeded by coldness and numbness of his feet, which gradually extended upwards with diminished power of motion, until, after several weeks, it terminated in perfect loss of motion of both lower extremities, with retention of urine. There vvas 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, blister- ing, &c. he recovered a slight degree of motion, but no power of the bladder. He then began to be affected with spasms of the mus- cles ofthe back and abdomen, with a very uneasy sensation of tight- ness across the abdomen, and at times across the lower part of the thorax. The spasms occasionally assumed the characters of opis- thotonos, and at one time he had almost incessant hiccup, which con- tinued in a most violent degree for several days. After the employ- ment of various antispasmodics, this subsided under the use of musk. During the course of these symptoms, he frequently complained of pain in various parts of the spine, at first in the lower part, and after- wards higher up; and the feeling of numbness extended gradually upwards, till it reached nearly the upper part ofthe 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, terminating in the morning by very profuse perspiration, but this was strictly con- fined to the parts which were not palsied, and there never was the smallest moisture on the lower extremities. He had also, in the upper extremities, a frequent feeling of intense heat, while the lower con- tinued cold and benumbed. 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 motion 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 spot, on various parts, especially behind the ear, and sometimes to the tip of the ear. This pain seemed to abate under the use of arsenic; but soon return- ed, 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 headache was se- vere, and the power of the limbs so much impaired, that he vvas en- tirely confined to bed. In a few days after his return, the right arm became paralytic, and his speech considerably impaired. After a day or two, these symptoms rather subsided, but in the following night he became comatose, and died in the afternoon. There never vvas complete loss of sensation of the affected limbs; he had only com- plained 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 252 RAMOLLISSEMENT OF THE 60RD. the inner susface of the dura mater of the spinal cord. The whole cord was of a pale rose-color, and in a state of complete ramollisse- ment 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 a degree of soften- ing 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 ofthe 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 affec- tion ofthe cord, when the disease advances in so gradual a manner as in this case, and terminates in disorganization so complete and exten- sive. In tracing the history ofthe analogous disease ofthe 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 continue for a considerable time in the state of simple in- flammation, and then subsides; or that it may terminate by a permanent change in the structure of the part, generally with some degree of in- duration. 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 character 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 gradually extended over the hand and arm. Afier some time the other hand and arm became affected in the same manner, and, after a year, the lower extremities. All the limbs then became paraly- tic, 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 spas- modic contractions with much pain. The patient died in this state at the end of eight years from the commencement of the disease. Along nearly the whole length of the cord, there was a central cavity full of a soft grey mucus. It was considered as arising from ramol- lissement 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 RAMOLLISSEMENT OF THE CORD. 253 were entirely motionless, but preserved their feeling. There was ex- tensive ramollissement of the anterior pillars of the cord: and a very remarkable circumstance was, that the softening 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 intel- lectual faculties had been almost entirely obliterated, but the motion of his arms continued entire to the last. Such are the difficulties and obscurities of this interesting subject. A different course of symptoms occurs in a remarkable case describ- ed by M. Rullier.* A gentleman, aged 44, who had slight curva- ture 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 be- came rigid, contracted, and entirely motionless, and the points of the fingers were forced 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 difficulty. He lived six years in this state, and died of pectoral complaints. A portion of the cord, six inches in length, occupying two-thirds of the cervical portion, and part ofthe 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 pre- served their nervous matter, to their junction with the membranes of the cord, but in the anterior roots it was destroyed, and they were re- duced 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 trie cord. In one case, there was loss of power of the whole body without loss of sen- sibility, and the disease was in the anterior part ofthe cord. In anoth- er, there was complete palsy of the legs, and partial palsy of the arms, while the sensibility was everywhere morbidly increased. The med- ullary matter ofthe cord was singularly contracted in volume. The anterior part of its upper half was of a reddish-brown color, and as it were macerated; the roots ofthe nerves inserted there were so wast- ed as to be scarcely discernible, while the posterior roots wrere preter- naturally large. A case mentioned by Ollivier seems to establish the inflammatory origin ofthe ramollissement ofthe cord, and at the same time shows the insidious and dangerous nature of injuries 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 af- fected in the same manner; and some projection of the vertebrae at the affected part was then first observed. He had afterwards convul- sive motions of the limbs, and died about a month after the appear- ance ofthe palsy. On dissection, there was found false membrane of * Journal de Physiologie, 1823 254 RAMOLLISSEMENT OF THE CORD. an inch in extent, with purulent matter, betwixt the bone and the mem- branes ofthe cord at the affected part; and the portion ofthe cord in- cluded in the diseased membrane vvas entirely diffluent like cream. Above and below this portion, the cord was of a natural consistence, but highly injected, and of a deep red color, especially below the soft- ened part, where the redness was intense. I shall conclude this part of the subject with the following very re- markable 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 ofthe body, when the spinal cord was examined. I shall simply relate the case, without entering upon any of the very interest- ing 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 making any great ex- ertion. For a month before his death the pain of his back had been more severe, and he had great difficulty of swallowing. 'His general health, however, was very little impaired; and on Monday, 15th July, he carried a burden 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 attempting to come out, fell among stones. When he was taken up, he- was bleed- ing 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 restless and partially insensible, and talked incoherently; he had several attacks which were represented as con- vulsive, in which his eyes became fixed, and there was much tremu- lous 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 before his visit, he had brought up a large quantity of blood, which ran from his mouth in a full stream, and then coagulated. 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 con- stant 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 involuntary dis- charge of urine. In the evening, he again vomited blood in consider- able quantities. (17th,) There was little change, except that he re- covered the power of the bladder ; perfect palsy of the arms contin- ued, but his legs were in almost constant motion. There was no re- turn 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, soon after, was seized with vomiting of blood to a great extent, and died almost immediately. UNDEFINED SUPPURATION OF THE CORD. 255 Inspection.—The heart and lungs were healthy ; the stomach con- tained 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 albuminous-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 ofthe cord, from about the 3d to the last dorsal vertebra, was of a yellow- ish color, and in a state of extensive ramollissement, especially about the centre of this space, where it was entirely diffluent. On remov- ing the cord, the anterior part of the spinal canal, viewed from be- hind, 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 ramollis- sement. These two morbid conditions were not acurately discrimin- ated till lately; but in the brain there seems every reason to believe that they are entirely dis.tinct^ and it is probable that they may like- wise be so in the cord. 1. A woman, aged 23, who had suffered considerably from syphilis, was seized with severe quotidian intermittent, which proved very te- dious, and resisted all the usual remedies. After some time, it was accompanied by pain in the lumbar region, diarrhoea, tormina, tenes- mus, general debility, and emaciation. About three months after the commencement of the fever, she began to be affected with weakness and convulsive motions ofthe left lower extremity, resembling chorea. In walking, the leg was dragged, and, if she attempted, by a strong effort, a greater degree of motion, it was thrown into convulsive dis- tortions. Soon after, the left arm became affected in the same man- ner, and there were also convulsive motions of the face and eyes. The complaint in the bowels now ceased, but the other symptoms in- creased, and the affection of the limbs soon amounted to nearly com- plete 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 convulsions. Her death happened rather more than a month after the commencement of the convulsive affection of the leg. On dis- 256 . ABSCESS OF THE CORD. section some serous effusion was found in the thorax, and in the ven- tricles ofthe brain. The spinal cord was soft and flaccid, and to a considerable extent suppurated. Its investing membrane was in many places covered by a puriform fluid; and there vvas also serous effusion in the spinal canal.* 2. A young soldier, who had lately recovered from a petechial fever, was affected with pain in the dorsal vertebrae, difficulty of moving the lower extremities, retention of urine, involuntary discharge of feces, general debtlity and emaciation. A variety of treatment was employed for several months without 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, com- pletely immovable and speechless, but in possession of his intellectual faculties, 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 preserved its figure, but was very soft. Its investing membranes, and the periosteum lining the canal of the vertebrae, were destroyed 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 hospinal of Crema, in the spring of 1804, with no other complaint than general weakness and depression, for which no cause could be assigned. He lay con- stantly 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 suspicions .were entertained that he was feigning; but as winter 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 soundj 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.f § 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 oedematous. After four days the speech could not be understood; pulse feeble; increasing debility; stertorous breathing; and she died in a week. * Brera Delia Rachialgite, cenni patalogici. In Atti delP Accad. Ital. torn. i. t Brera, ut supra serous effusion in the spinal canal. 257 Inspection.—The brain was sound, but the pia mater was injected. In the centre ofthe right column of the spinal cord, in the middle of the cervical portion, there was a cavity three inches long, and two or three lines in diameter. Tt was full of a soft matter like pus, which became more consistent towards the parietes of the cavity. It seem- ed 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 thick- ness, and were formed by the healthy white matter. In the left col- umn 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 resembling ramollissement of the substance of the cord. The membranes of the cord were hardened at the part, and also at a part in the dorsal region.* SECTION III. serous effusion in the spinal canal. I place this appearance by itself, abstaining from any hypothetical speculations in regard to the origin of it. I have already alluded to the ambiguity which aitends serous effusion when it occurs between the dura inater and the inner membrane ofthe cord, on account of the free communication, which this space has with the cavity of the crani- um, or at least with the cellular texture of the arachnoid ofthe 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 con- nexion with disease ofthe spinal canal. The following is the most distincly marked case of this affection that has occurred to me. Case CXLIX.—A strong healthy child, aged nearly 2 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 violent and irregular action of the heart, and a peculiar spasmodic action of the diaphragm. The second fit left her in a state of coma from which she never recovered. She took food or medi- cine when they were put into her mouth, but showed no other appear- ance of sensibility. The eye was completely insensible, and the pulse very frequent. She had afterwards several slight attacks of convul- * Valpeau Revue Medicale, 1826. 33 258 serous effusion in the spinal canal. sion, 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, except some appearance of increased vascularaty, and slight effusion under the arachnoid. The brain and cerebellum being removed, there was a copious discharge of bloody fluid from the spinal canal. The ca- nal being laid open, there was found a copious deposition of color- less fluid, of a gelatinous appearance, betwixt the canal ofthe verte- brae and the dura mater of the cord. It was most abundant in the cervical and upper part of the dorsal regions. Between the mem- branes of the cord there remained a small quantity of the bloody fluid which had flowed into the cavity7 of the cranium. The substance of the cord, at the upper part, seemed softer than natural, and very ea- sily torn. All the viscera of the thorax and abdomen were perfectly healthy. The foramen ovale vvas 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, especially if we should find that this fluid is bloody, while the effusion under the arachnoid of the brain is colorless. In a child, aged between 3 and 4 years, mentioned by Ollivier, who died with symptoms of opisthotonos, difficult deglutition, and co- ma, he found deposition of a red and very consistent fluid, in the cel- lular 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 depending 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 occa- sionally 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 accompanied by dyspnoea, 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 para- lytic, 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, but the cord was SPINAL APOPLEXY. 269 sound; there vvas also fluid on the surface of the brain, but none in the ventricles" 2. A child, aged 12 months, whose case is briefly related by Mr. Chevalier, after appearing to be in much pain, lost the use of the in- ferior 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 cholic, fell into paralysis. It began at the upper part of the arms, and extended gradually to the points of the fingers. After- wards 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."J: 4. A man mentioned by Portal had numbness of the inferior ex- tremities, followed by paralysis of them, and extensive oedema. Af- ter some time the arms became affected in the same manner, and the oedema extended over the whole body. He died comatose. On in- spection 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. In was full of serous fluid, and extended as far as the third dorsal vertebra. SECTION IV. SPINAL APOPLEXY, OR EXTRAVASATION OF BLOOD IN THE SPI- NAL CANAL. Case CL.—A child, aged 7 days, 1st September, 1818, was ob- served not to suck, and appeared as if he were prevented by some- thing which impeded the motion of his tongue. Through 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 veryhttle force it could be opened. On the third day he was seized with convulsion, which recurred at various intervals, sometimes in the form of tonic spasm of the whole body, and sometimes of violent con- vulsive agitation. On the fourth ihe convulsion continued, 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 coagulum of blood, lying between the bones and the membranes of the cord on the pos- terior part, and extending the whole length of the cervical portion. * Morgagni de Causis et Sedibus, &c. Epis. 10. Sec 13. t Med. Chir.. Trans- vol. iii. X Boneti Sepulchretum Anatomicum, torn. i. 260 SPINAL APOPLEXY. This is the only case that has occurred to me of this remarkable affection; but, as it appears to be uncommon, and to present some very interesting phenomena, I am induced to add the following exam- ples. 1. A lady, aged 40, had headache and pain of the back; after a few days the pain of the back became very acute, and violent con- vulsion took place, which was fatal, after continuing five or six hours. All was sound in the brain, but extensive 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, extending from the cervical vertebrae quite to the sacrum. After a few hours he was seized with paraplegia, and incontinence of urine and feces; 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 ofthe 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 color, and very soft.f 3 A young lady, aged 14, had headache 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 fajal in five or six hours. The spi- nal canal was found filled with extravasated hlood, in the lumbar re- gion, which had been the seat of the pain. The brain and all the other viscera w7ere sound.\ 4. A miller, in lifting a heavy sack, suddenly lost the use of his lower extremities, and died in fifteen days. Extravasated blood was found, mixed with sanious matter, in the spinal canal. The mem- branes 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 apoplec- tic, but in which he retained his mental faculties to the last. No dis- ease was discovered in the brain, but there was a great quantity of extravasated blood in the spinal canal.§ 6. A man received a violent blow on the three inferior lumbar ver- tebrae, 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.IT 7. A boy, aged 14, received a violent jerk of bis neck by a cord * Ollivier, ut supra. t M. Gaultier de Claubry, Jour. Gen. de Med. 1808. X Chevalier Med. Chir. Trans, vol. iii II Chevalier, ut supra. § Da Hamel, Reg. Scient. Acad. Histor. An. 1683. Sec. 5, cap. 2. p. 264. IT Morgagni, Epis. 54. FUNGUS OF THE CORD. 261 which was thrown over his head as he was swinging forward in a swing. He felt no bad effect at the time, but, after some time, be- came inactive and weak in the limbs, with stiffness of the neck, and difficulty in moving his head. Nine months after the accident, weak- ness of his limbs increased to paraplegia; and soon after he had par- alysis 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, which was first observed during sleep, but afterwards continued while he wasaw7ake; 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 servical verte- bra.* 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 hemiple- gia, from the effects of which he never entirely recovered. The pal- sy, which at first was hemiplegia of the left side, gradually changed into paraplegia, and he had several minor attacks, characterized by pain of 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 36 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 between the membranes. The cord itself was sound, but its membranes exhibited traces of inflam- matory 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 chord, 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. * Howship's Observ. in Surgery and Morbid Anatomy, p. 115- 262 FUNGUS 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 difficul- ty 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 involuntary con- vulsive motions of the whole body. After another long interval, his right arm became benumbed; he was also seized with dyspnoea and difficulty of swallowing, and his body was much emaciated. His bow- els were loose; his urinary functions were natural. His death hap- pened suddenly, nearly four years after the accident. His intellectu- al faculties had remained entire; his lower extremities had Been for a considerable time weak and unsteady, but not entirely paralytic, 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 cervi- cal vertebrae was found remarkably firm, and the membranes of this portion were so dense, that there wasgreat difficulty in cutting through them. . The medulla oblongata appeared one-third larger than natural. The pia matter was thickened, and, towards the falx, there vvas some appearance of suppuration; the ventricles were full of water. The lingual and brachial nerves, at their origin, were very compact or near- ly tendinous. This hardness was found, in the cervical nerves, to be owing to the density ofthe 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 con- siderably 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 tumor. He was then affected with complete paraplegia, incontinence of urine and feces, and extreme emaciation; and at length died gradually exhausted about six years after the accident. On dissection, the tumor was found to consist of a large fungous mass resembling the medullary sub- stance of the brain, which took its origin from the spinal cord, and had extended itself upwards and downwards, from the third dorsal ver- * London Medical Observations and Inquiries, vol. iii. INDURATION OF THE SPINAL CORD. 263 tebra to the coccyx. Many of the vertebrae, both dorsal and lumbar, were extensively carious on the posterior part, and some of the lum- bar vertebrae had nearly disappeared. There was a general softening of all the bones ofthe spine and ofthe sacrum and ilium.* 3. A man, aged 20, in the beginning of 1815, had first impaired 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 vvas relieved by diuretics, and continued better till May, when he had pain, tender- ness, and distention 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 ofthe 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 cervical ver- tebrae 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 tubercular mass, of the firmness of the pulmonary tubercles not suppurated, and of a greenish-yellow col- or. This mass extended 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 ramollissement, which af- fected chiefly the anterior columns; but the posterior columns were also slightly softened, in a space corresponding 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.f 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 color. From the por- tion which was thus chiefly degenerated, in the middle of the dorsal region, the substance of the cord formed a canal, tapering upwards * New London Med. Journal for 1792 t Serres, Anat. Comp. de Cerveau, torn. ii. p. 234. 264 COMPRESSION OF THE SPINAL CORD. and downwards, filled with a watery jelly. There was also some scrofulous tubercular matter at the portion principally diseased. SECTION VI. INDURATION OF THE SPINAL CORD. This part of the pathology of the cord is exemplified in the remark- able 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 mo- tion, 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 be- fore death, when both became remarkably slow; the pulse being from 30 to 40 in a minute. On dissection, the brain and all the viscera 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 membranes 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 al- ready referred to in regard to the brain. The most common appear to be fleshy and albuminous formations, tubercles, hydatids, and ossi- fications. 1. A woman, aged 36, had first some convulsive motions, which soon ceased; then acute pain of the left arm with headache; the arm became weak, and gradually completely paralytic. She then had convulsive motions of the lower extremities, which also became com- pletely paralytic. The right arm next became painful, and the mo- * Portal, Cours d'Anatomie Medicate, torn. iv. COMPRESSION OF THE SPINAL CORD. 265 tion of it was impaired, but not entirely lost. The inferior extremities became oedematous; the inferior half of the thorax, and all the parts below, 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 gradually 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 color; it was about three lines in thickness at the thickest part, and covered the anterior surface ofthe cord, from the sixth cervical nerve to the third dorsal: and the part of the cord which vvas covered by it was considerably flattened. Internally, the tumor was of a firm fleshy consistence, and of a yellowish-white color. On many parts ofthe arachnoid ofthe cord, cartilaginous scales were observed.* 2. A young man, aged 14, received a blow upon the spine between 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 towards 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 increased till, in a short time, they became entirely para- lytic. About the same time, he lost the power of retaining his urine and feces. He had continued in this state for two or three weeks, when his arms became paralytic, and-he then lost the power of mov- ing his head. He died on the following day, about three months after receiving the injury, having continued sensible to the last. During the progress of the disease, he frequently complained of great oppres- sion and pain darting through the chest. On dissection, the viscera ofthe thorax and abdomen were found to be healthy. Some bloody serum escaped in opening the head, but the brain in other respects was sound. Much bloody serum was discharged from the spinal ca- nal, 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 ofthe 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. trans- verse 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.f 3. Tubercles are found of various sizes, either in the substance of the cord or attached to its membranes, and they present the same characters as the tubercles of the brain. The symptoms vary exceed- • Velpeau, Arch. General, de Med. January, 1825, t London Medical Obs- and Inq. vol. iii. 34 266 COMPRESSION OF THE SPINAL CORD. ingly, according to the seat and size of the tubercles, or as they hap- pen 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 tubercle, the size of a nut, was found betwixt the dura mater and the arachnoid ofthe cord at the third cervical vertebra. In a case by Bayle, there was tonic inflection of the forearm, 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 to the cord at its lower extremity* Harderus found a tumor the size of a nutmeg, compressing 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 vvas complicated with disease ofthe lungs and .the liver. The leading symptoms were, severe headache, oppressed breathing, and, a few days before death, violent convul- sions. To the various examples now given, of tumors and tubercles ofthe cord, I shall only add a case by M. Gendrin, which presents some hi' teresting characters. A woman, aged 23,'after recovering from ep- idemic cholera, felt great weakness, especially of the lower extremities, with anorexia, thirst, and occasional diarrhoea. After two months, the motion of both legs was found greatly impaired, especially of the left, in which there vvas also diminished sensation, and a pain which extended from the origin ofthe sciatic nerve quite to the extremity of the toes; and both limbs were affected with a sense of coldness and prickling. Soon after this she began to have pain in the lumber re- gion, and this was succeeded by acute pain in both limbs, with convul- sive retraction ofthe toes. This pain vvas most acute in the left limb, and there was now increased sensibility of the left foot, so that the slightest touch produced a sense of laceration; and this morbid sen- sibility afterwards extending 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 vvas continually numb, but some degree of motion remained in both. On inspection, there was found, at the lower extremity 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 col- umn, in particular, was much distended and flattened by it. 4. Hydatids in the spinal canal have been mentioned by various writers. A woman mentioned by Esquirol became epileptic after a fright, and the fits returned every second or third day with great vio- lence for three years. She then became comatose after one of the par- DESTRUCTION OF THE SPINAL CORD. 267 oxysms, 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 was opened, and the spinal cord was felt by the fin- ger exposed at the bottom of it, after a large quantity of hydatids had been discharged. 'Xhe patient remained paraplegic, and afterwards died, gradually exhausted by the discharge from this cavity. 5. Ossification of the membranes of the cord has been observed in several cases. In a woman who had been epileptic for five years, and died suddenly in one of the fits, Esquirol found the sheath of the spinal cord, on ils external surface, covered through its whole extent with osseous scales, from one to two lines in diameter. In a case de- scribed by M. Barbier,* the affection began with prickling and numb- ness of the legs, which extended very gradually, and vvas afterwards accompanied by acute pain in the limbs,- and after several months ter- minated in complete paraplegia, with incontinence of urine. The patient, a woman of 55, centinued 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 vomit- ing, fever, delirium, and convulsive motions of the limbs. She died after a short illness, the duration of which is not distinctly stated, but seems to have been eight or ten days. At the third dorsal vertebrae, there was an ossification of the membranes of the cord half a line in thickness, three lines broad, and two inches long. The inner surface of this production was concave and covered with a soft membrane; and the portion of the cord included in it was almost destroyed, the membrane containing only a small quantity of viscid fluid. Above this, the cord vvas firm and healthy; below, it was much wasted. 6. The cord may also be compressed by a diminution ofthe spinal canal, but this appears to be a very rare occurrence. It was, how- ever, observed by Portal. The canal of the last dorsal and two upper lumbar vertebrae was diminished one half, and its inner surface was rendered unequal by numerous small bony eminences. The in- ferior extremities were much wasted. SECTION VIII. DESTRUCTION OF A PORTION OF THE SPINAL CORD. A man, whose case is related by Mr. Copeland, had paraplegia, * Traite Element, de Mat. de Med. 268 CONCUSSION OF THE SPINAL CORD. dysuria, obstinacy ofthe bowels, and a feeling of tightness across his belly, as if a broad band had been bound tightly round it. His health had been declining for more than a year, 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 ofthe vertebrae, but without loss either of sensibility or motion ofthe limbs. Velpeau has described several cases, in which, in connexion with caries of the vertebrae, the cord vvas completely destroyed for the space of several inches, the patient having died of gradual marasmus without any appearance of paralysis; and in Ma- jendie's journal, 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 sensibility, but the legs were not affected. Ollivier has also observed 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 ofthe limbs. SECTION IX. CONCUSSION OF THE SPINAL CORD. A severe blow upon the spine frequently occasions an immedi- ate loss of power of the parts below the seat of the injury, without producing either fracture or dislocation of the vertebrae. The extent ofthe parts affected will of course depend upon the seat ofthe injury. Paraplegia and retention of urine are the symptoms which most com- monly come under our observation; but, if the injury be on the upper part of the spine, there may also be paralysis ofthe upper extremities, difficulty of breathing, and affections of the voice. In tracing the farther history of this affection, the following circumstances are worthy of attention. 1. Concussion ofthe cord may be speedily fatal without producing any morbid appearance that can be detected on dissection. Many cases of this kind are on record. Boyer mentions a man who re- ceived an injury of the spine by falling into a ditch. He was imme- Copeland on Diseases of the Spine. CONCUSSION OF THE SPINAL CORD. 259 diately affected with complete paraplegia, 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 mentions four fatal cases of concussion of the spine, in none of which could any morbid appearance be detected, either in the verte- brae 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 feces, 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 speeeh, loss of voice, and paralysis of the lower extremities, the superior extremities remaining unaffected. After seven days he recovered his voice and speech, and soon after the palsy also disappeared. In summer 1S16, I saw a man who had been employed in blowing a rock near Edinburgh. Not having retired to a sufficient 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 stale a few hours after the accident, when he also complained of violent pain, be- ginning in the seat of the injury, and extending downwards along the thighs. On the back there was an extensive swelling, which made it impossible to ascertain the stale 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 re- covered, 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 re- covered 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 bead, and he had retention of urine and obstruction of the bowels. After eight or ten days, he was 270 CONCUSSION OF THE SPINAL CORD, affected with anasarca ofthe limbs, and a sense of prickling followed by severe pain, but without any power of motion. After lying seve- ral weeks in this state of perfect paralysis, he began to recover a slight degree of feeling and motion, beginning 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 continued 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 blad- der and the bowels, in this case, is somewhat remarkable. He had first complete retention of urine, requiring the use of the catheter for fpur weeks; he then recovered the power of passing his urine, but could not retain it; it flowed involuntarily, and after some time longer, he recovered the power of retention. The bowels were not moved without strong glysters for six weeks; after this the stools passed in- voluntarily for four weeks^ and he then recovered the natural action. A man, mentioned in the Journal Unjvejfsel. 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 lower extremities were entirely deprived of sense and motion- He bad afterwards retention of urine, tumefac- tion ofthe abdomen, headache, dilatation of the pupil, extreme 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 feeling of the penis and scrotum, and of the anterior, pesterior, and interior part of the thighs, without any loss of motion. In such cases the sensibility of the parts some- times returns gradually, and in others the affection is, permanent. 4. It may produce permanent paralysis. This may occur imme- diately, or the first effects of the injury may be recovered from, and a new diseased action may take place after a considerable time. Sev- eral examples of this have already occurred under the foregoing heads. The slight nature of the first symptoms, in such cases, and the slow- ness of their progress, will be illustrated by the following case. Case CLI.—A man, aged 54, about twenty-five years ago, fell from the branch of a tree, and lighted on the sacrum. He was carri: ed home, complaining of pain in the lower part of the spine, and en- tirely paralytic in his lower extremities. In this state he was confin- CONCUSSION OF THE SPINAL CORD. 271 ed to bed about twelve days, and then recovered, so as to be able to follow his usual employment; but from this time he was affected with a peculiar feeling 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 tliigh, and was soon followed by paralysis of the right thigh and leg. He was then confined to bed with perfect paraplegia for about two years. 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 improvement, when I saw him for the first time, upwards of fifteen years ago. His spine was free from distortion, but he 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; be 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 distressed with incon- tinence of urine. The morbid action which takes place hi such a case as this, will be illustrated by the facts which have been already recorded. It is prob- ably of the nature of chronic inflammation of the cord or its mem- branes, terminating by some of the morbid Conditions which have al- ready been referred to. We have seen that such affections may su- pervene upon very slight injuries of the spine, which do not at the time of receiving them induce any urgent symptoms, and perhaps at- tract little or no attention. Sometimes they take place after so long an interval that the patient has forgotton 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 paralytic in the lower extremities, several months after a slight injury of the spine, occasion* ed by striking his back against the corner of a table. A gentleman walking in the fields near Edinburgh sprained his back slightly in leap* ing over a wall. He felt little uneasiness at the time, but, after seve* ral weeks, his lower extremities became paralytic. In this state he continued 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 ths stomach and back with contraction ofthe legs; and this was followed by weak- ness ofthe legs, which, after ten days, increased to perfect paraple- 272 CONCUSSION OF THE SPINAL CORD. gia. Issues were then inserted, and he was able to walk in three months. Every injury of the spine should be considered as deserving mi- nute attention, and the most active means should be employed 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 in a very insidious manner, even after inju- ries which were of so slight a kind that they attracted at the time little or no attention. When the injury is of a more violent nature, there is indeed another object of attention, that is, fracture or dislocation of the vertebrae. But we have seen that the most'urgent 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 ifae vertebrae, in conse- quence of the external swelling which lakes place. It is likewise 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 impossi- ble to discover it. A case is mentioned by Camper, in which para- plegia 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 lum- bar 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 similafcase by Boyer, the man recovered, but with palsy of ther 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, meutioned 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 low- er dorsal vertebrae, which soon healed, and he was afterwards able for long marches. . After a considerable time, the place became pain- ful, suppurated, and was opened; and a piece of the point of the sword, two inches long, vvas 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 tra- versed the^p«»l canal, and had lodged in the opposite side. A man mentioned in the first volume of the Archives Generales de Medeeihe, AFFECTIONS OF THE BONES OF THE SPINE. 273 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 ofthe body except the face. Any part of the thofax, the abdomen, or the leg or arm of that side, could be pinched with any degree of force without feeling. The power of motion was preserved, though it seemed weaker than in the other side. His health was otherwise 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 im- portant subject; but there are some circumstances relating 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, accompa- nied by paraplegia, it is well known that the paralysis is not produced simply by the distortion; for the distortion may exist in a very great degree without paralysis; and, when they have existed together, the paralysis may be entirely removed, while the distortion remains undi- minished. It appears that it is the inflammatory action of the parts which deranges the function of the cord; that the effects of this in reference 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 irreme- diable. The original disease appears to be in some cases seated in the ligaments and membranes; in others, in the articulating surfaces and intervertebral cartilages; and in others, in the bodies of the ver- tebrae. It is w7hen the bodies of the vertebrae are extensively affect- ed, that the caries which follows produces distortion; but even in this 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 mere- ly to shorten the spine, without distorting it. This is said to oc- cur most frequently in the lumbar vertebrae. The case of a boy re- lated by Dr. Armstrong, is very important. He had involuntary dis- charge of urine and feces, difficult breathing, and paralysis of all the extremities except a very imperfect degree of motion in the left arm. There was much pain and tenderness on pressure in the cervical ver- tebrae, but no distortion. He recovered completely in a few months, the vertebrae that had been affected remaining in a state of anchylo- 35 274 AFFECTIONS OF THE BONES OF THE SPINE. sis. In this case, the disease was probably confined to the articu- lating surfaces. Mr. Copeland gives a plate, in which three of the dorsal vertebrae are represented as united by anchylosis, the interver- tebral cartilages being removed, but without any loss of substance in the bodies of the vertebrae. In this case, paralysis had taken place, but there was no perceptible distortion. In attending to such cases in practice, therefore, it is not sufficient to ascertain the existence or non-existence of distortion. 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 recommend- ed 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 na- ture, 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 always be made with the utmost care, when any of those symptoms 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 margin of the ribs, and a peculiar oppression and tightness across the region of the stomach; various affections of the breathing; difficulty in discharging the urine and feces, or difficulty in retaining them. Complaints such as these have sometimes 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 accompanied 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 de- tected by the most careful examination of the spine; but these are quite distinct from the particular class of affections which are here referred to, and in regard to which we cannot be too attentive in watching the very earliest indications. One symptom, in particular, which should always be contemplated with much suspicion, is a feel- ing of tightness or constriction along the margin of the ribs, as if a AFFECTIONS OF THE BONES OF THE SPINE. 275 tight band were passed across the stomach. This is generally ac- companied with a feeling of distention in the lower part of the abdo- men, as if the bowels had in part lost the power of propelling 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 oc- curred to me, symptoms of this kind had existed for nearly three months before a projection vvas discovered in one of the lower dorsal vertebra?, 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 at- tended 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 diffi- cult breathing; her limbs were not affected, except that she was more easily fatigued than her companions. One of the dorsal verte- brae was found to project a little, and by topical bleeding and-blister- ing on this part, and rest in the horizontal posture, all her complaints were removed. A man mentioned by7 Dr. Jebb, had pain under the short ribs on both sides, cough, and irregular pulse. From the parts affected lancinating pains extended downwards along the thighs, occasioning much uneasiness in walking, resembling the pains of rheu- matism. The ninth or tenth dorsal vertebra was found to protrude, and by issues applied 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 pos- ture; but some cases are on record, showing in certain conditions of the disease the beneficial effects of mercury. 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 recovered 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 transac- tions of a Society for the Improvement of Medical and Surgical Knowledge, is related the case of a man, who had squinting, difficulty of swallowing, indistinct articulation, paralysis ofthe left leg and arm, and protrusion of several of the cervical vertebrae. Under a course of mercury all his complaints disappeared, and the protrusion ofthe vertebrae was diminished, though net entirely removed. Several cases have recovered by confinement to the horizontal posture without any other remedy; this occurred in Dr. Armstrong's case, lately re- ferred to. The spine may be affected with extensive caries without the exist- 276 AFFECTIONS OF THE BONE S OF THE SPINE. ence 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 mediastinum, with caries of several of the ver- tebrae, of such extent that the spinal cord was exposed in several pla- ces. 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 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 vvas 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 prevented him from rais- ing 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 accounted 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 Bertin has described a preparation in which the atlas was so anchylosed with the occipital bone, that its posterior arch crossed the centre of the foramen mag- num. 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 ca- ries 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 affections of the pro- cessus denatus. 1. It may be affected with caries without producing any urgent symptoms, until it suddenly give way and prove fatal. A man, men- tioned by Mr. Copeland, had been using mercury for a disease in the tibia, and had for some time 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 pro- cessus 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 ofthe head was insupportable, so that she was constantly confined to the horizontal posture, and almost to * Edin. Med. Com. vol. iii. AFFECTIONS OF THE BONES OF THE SPINE. 277 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 processus dentatus was entirely destroyed by ca- ries. 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 examples 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 wheelbarrow suddenly went from before him, and he fell with his chin upon the curb-stone. He vvas dead in a few seconds; the processus 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 vvas received into the Infirmary of Edinburgh, who had been accus- tomed 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 diffi- culty, 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 ofthe neck and back, resem- bling tetanus; his articulation was slow and difficult, and the pulse 54. These complaints had begun about six weeks before, and had been increasing gradually; difficulty of swallowing vvas one of the first sym- 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 ligaments had given way on the left side of the processus dentatus, so as to allow it to compress the spinal cord. No other disease could be discovered in any ofthe viscera. For the following important case I am indebted to Dr. Hunter. It illustrates in a striking manner many of the observations made in this section, artd 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, which, to a cer- tain 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 Match. 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 278 AFFECTIONS OF THE BONES OF THE SPINE. back part of it. Several tumors had also appeared on the scalp, in which fluctuation was felt, and on opening them, the bone beneath vvas 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 mat- ter, in small quantities. 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 continued. 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 considerable quantity of matter which lay in contact with the vertebra; and the surrounding soft parts were in a state of pulpy degeneration. The four upper ver- tebrae were found to be more or less affected with caries, which vvas most 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 vertebra. The membranes of the cord were thickened, and the cord itself vvas a little softened at the upper part, but in no re- markable degree. A remarkable case, analogous to this, is mentioned by M. Mey- rieu.* The patient had pain and stiffness ofthe neck, his head being bent to one side, and immoveable; difficulty of swallowing; 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 legitaments, so that the atlas was luxated from the occipital bone. * Bull, de la Soc. de Med. AFFECTIONS OF THE BONES OF THE SPINE. 279 I conclude this part of the subject with the following case, which shows disease of the processus dentatus, complicated with a new form- ation, presenting the character of fungus haematodes. Case CLIII.—A gentleman, aged 22, of a scrofulous habit, in the early part of his life had suffered amputation on account 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 com- plain of pain and stiffness of the neck, referred chiefly to the left side of it, and much increased by the motion of the head. The pain sometimes extended into the larynx, and backwards towards the scap- ula. 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 dyspoena and hoarseness. There was now also severe fixed pain referred to the back ofthe head, and much increas- ed 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 ofthe 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, the lower extremeties 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 pharynx, &c. were healthy, and no disease was discovered in any of the vertebrae in their external aspect. The brain and cerebellum 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 color, which, when cut into, presented a variegated structure, resembling fungus haematodes. 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 de- stroyed so as evidently to allow it to encroach upon the area of the spinal canal, and to compress the cord. The spinal cord at the upper part vvas 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 corresponding affections of the brain. In the more acute affections, we must, of course, rely chiefly on free general and topical bleeding, assisted by blistering, purgatives, and the other usual auxiliaries. When the affection is in a more chronic 280 PATHOLOGY OF THE SPINAL CORD. form the treatment will consist chiefly in local applications, as topi- the bleeding, blistering, and issues, 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 an the other, in quick succession, and repealed in this manner to a considerable number. In some of the cases great benefit is also obtained from continued moderate purging. SECTION XL CONCLUDING OBSERVATIONS OF 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 ofthe spinal cord, we find affections of all the principal organs of the body. In the parts connected with the head and neck, we find distortion of the eyes, convulsive affections of the face, dif- ficulty and loss of speech, loss of voice, contraction of the jaw, re- sembling 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 re- gion of the diaphragm, and difficulty of breathing, which, in some cases, has been permanent, and in others, has occurred in paroxysms, resembling asthma. In the organs ofthe abdomen and pelvis, we find vomiting, pain ofthe bowels, resembling colic; 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 directly from the affections ofthe spinal cord, especially as we observe remarkable diversities and considerable want of uniformity 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 conjecture, in regard to the influence ofthe spinal cord, in several diseases which have hitherto been involv- ed 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 being investigated by farther observation. They have chief- ly referred to the following points. CONCLUDING OBSERVATIONS. 281 Spasmodic Diseases.—Several writers of eminence have conceived that many spasmodic and nervous diseases have their origin in affec- tions ofthe spinal cord. Hoffman, in his Essay De Morbis Discernen- dis, directs us to distinguish betwixt epilepsy and convulsions. In the former he says the membranes of the brain are affected, in the latter the membranes of the spinal cord. In his Treatise De Morbis Convulsivis, he divides convulsive affections into idiopathic and symp- tomatic. The former, he thinks, arise from irritation of the mem- branes ofthe spinal cord; the latter he supposes to depend upon dis- eases 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 intercostal nerves, and explaining the affections of the lungs, the larynx, &c in such diseases, by the connexion of these nerves with the par vagum. Lieutaud contends that all convulsive affectious, 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,. Fernelius, and Belfingerus (De Tetano.) Portal supposes that slight pressure on the spinal cord produces con- vulsion, and greater, paralysis; and he thus accounts for the one pas- sing 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 re- lated, and others are on record, which show, in connexion with dis- eases ofthe spinal cord, symptoms closely resembling those of chorea and tetanus. Hoffman mentions a boy, who, after a blow on the sacrum, vvas seized with a violent convulsive affection nearly resem- bling tetanus, with loss of memory, difficult articulation, and delirium. The complaint continued with great severity for five days, and after- wards returned at nearly regular periods for six months. Burserius relates the case of a man who died of tetanus, induced by exposure to cold after intoxication; on dissection a large quantity of viscid yel- low serum was found under the outer covering of the spinal cord. Frank also relates a case of" horrible tetanus," which was induced by a blow upon the spine, but he gives no account of the appearance on dissection. Several cases have been detailed in which, in vari- ous diseases of the spinal cord, symptoms occurred, closely resem- bling tetanus; and this important subject has been farther investigated by Dr. Reid, in bis work on Tetanus. Upon the whole, however, the truth appears to be, that though symptoms strictly tetanic do ac- company various affections of the spinal cord, the disease properly to be considered as idiopathic tetanus is entirely of a different nature, and that the pathology of it is still involved in great obscurity. 2. Colica Pictonum. I have referred to the case of a woman mentioned by Bonetus, in whom paralysis followed severe colic, and 36 282 PATHOLOGY 0? THE PPINAL CORD. extensive serous effusion was found under the membranes of the spi- nal cord. Privatius, as quoted by Sauvages, 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 ofthe last cervical vertebra, but no account is given of the dis- section. 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 Pictonum. They consider it as a real inflammation ofthe spinal cord, (Rachialgia Sat- urnina,) and on this principle they have proposed to treat it by blood- letting.* This opinion, however, has not been confirmed by farther and more accurate observation. 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 ofthe spinal cord, particularly the pain in the back, tremors ofthe limbs, and oppression of the breathing.f 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 about the cauda equina; there were also marks of inflammation in the brain and its membranes."}: 4. Epilepsy. M. Esquirol, some years ago, presented to the Fac- ulty of Medicine at Paris, a memoir on epilepsy, in which he states that he had examined the bodies of fifteen patients who died of this disease, and found the spinal cord affected in all of them. The dis- sections, 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 color. In several of the cases the medullary substance of the cord was softer than natu- ral at particular parts, and in one it was harder. In one case the spi- nal cord at the 11th and 12th dorsal vertebrae was soft and of a light brown color. 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 con- jectured that in this horrible disease the spinal cord is affected; and a case is related in Dr. Johnson's Medico-Chirurgical Journal for Oc- tober 1817, which seems to afford some probability to the conjecture. The case was well marked, violent, and speedily fatal. The mem- * Astruc, Q,usestio Medica, An morbo Colics Pictonum, reciius Rachialgiaj, venisec- tion t Ballonii Consilia Medica. + Rachetti della Struttura, dclle funzoni e delle IJalattie della Midolla-Spinali. CONCLUDING OBSERVATIONS. 283 branes of the brain were found highly vascular, with considerable se- rous effusion; but the principal marks of disease were in the cover- ings ofthe pons Varolii, medulla oblongata, and the upper part ofthe 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 ofthe other parts. M. Gendrin, 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 proceed from disease at the Origin ofthe phrenic nerves; and difficulty of speaking and of swallowing frequently depends, according to Portal, on " en- gorgement" in the cervical portion ofthe 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 allusion to some points which seem to be related to the subject, while they show the difficulties and obscurities which attend it. Several very remarkable cases have occurred to me which present- ed 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 numb- ness in the thumb of the left hand, which gradually extended over the whole hand and arm. The limb was then partially paralytic, and was likewise affected with involuntary motions exactly resembling those of chorea. This continued several 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 af- ter some time also got well. The legs then became affected with starting, 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 sacrum 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 color, as if it had been soaked in venous blood, and there was some bloody fluid around it. The sacrum was remarkably soft, and in some pla- ces carious; and it was covered externally by a deep and extensive sloughing sore. All the other viscera were healthy. 284 PATHOLOGY OF THE SPINAL CORD. 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 ofthe legs took place, he began to lose the power of his arms, and this also increased, till he retained in them 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 disease 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 vestige 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, weakness of the legs took place, which gradually increased tq 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, ex- cept a very slight motion of some of the fingers; but the internal functions were all entire, and her speech was distinct, except that, in speaking, she was sometimes seized with spasmodic twitches of the lips and lower jaw. She livid 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 exten- sively oedematous. In the same manner, if her head fell forward upon the thorax, it remained in that position until raised by an attend- ant. Her mind was entire. She died of four days illness, with symptoms of low typhus fever. I examined the body with the ut- most care, along with Dr. Pitcairn, 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 several CONCLUDING OBSERVATIONS. 285 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 accom- panied by pain, extending along both the arms; at first like rheu- matic pains with stiffness, 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 ofthe 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 po- sitions of the neck, in which she could swallow with greater facility than in others. Her pulse was good, the other functions were na- tural, and the motion of the lower extremities was not at all affected. About a fortnight before her death, she became affected with dys- pnoea, which occurred in paroxysms, sometimes very severe. An appearance of projection was now observed, with pain upon pressure in several of the lower cervical vertebrae. Issues were inserted in this place, and for a week she seemed better; she was free from dyspnoea, and the motion ofthe arms was considerably improved. On the evening of the 4th October, she became suddenly comatose with some convulsion, and had a peculiar 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 vvas a superficial redness like very recent inflammation; but, on the most careful examination, no disease could be discovered 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 remarkable 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 extend- ed over the hand, and then over the arm. The left lower extremity then became affected 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 ofthe 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 her- self 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 * Revue Medicale, May 1826. 286 PATHOLOGY OF THE SPINAL CORD. of fluid in the ventricles ofthe brain; but the brain itself, the cerebel- lum, 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 color of rust. Its centre was of the deepest color, and its circumference irregular, grad- ually losing itself in the surrounding substance; and it seemed rather harder than the other parts. The morbid appearance, in this singular case, has a remarkable re- semblance to the morbid condition" of a small part of the brain, form- erly referred to, and exemplified in Case CXXXV. It is probably the result of a slow inflammatory action, limited to a very small por- tion ofthe 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 pricking 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 af- fected in the same manner. She continued to go about for three hours, after which she was obliged to sit down from a feeling of fa- tigue; and after sitting for some hours, she vvas carried to bed. Next day, there was paralysis of all the limbs, but in the greatest degree on the left side. The sensibility ofthe parts was not impaired. Respi- ration was performed with a kind of effort, and at night became very difficult. On the third day, respiration was rather improved, but there was difficult deglutition. In the evening the difficulty of breathing in- creased, with frequent pulse and strong action of the heart, and she died at night. There vvas a slight appearance of infiltration of blood in the cellular tissue on the outside ofthe 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 vis- cera were in the most healthy state. I conclude this subject with a brief allusion to certain obscure and anomalous affections, which, like those now mentioned, present many ofthe characters of disease ofthe spinal cord, though their termina- tion in general is more favorable. The affections assume a great va- riety 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, CONCLUDING OBSERVATIONS. 287 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 affections 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 un- tractable. It is indeed difficult to say what treatment has any7 decided control over them; but the remedies which appear to be most bene- ficial are, free und 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,—some- times very suddenly, and without any cause to which thpir removal can be ascribed. One modification of these singular affections will be illustrated by the two following cases, which lately occurred to me in the same fam- ily. A strong and healthy girl, aged 8, of a full habit and florid com- plexion, was observed to stumble frequently in walking, and occasion- ally to fall; and this, without any farther warning, was followed in a very few days, by perfect palsy of both lower extremeties. I saw her about a fortnight after the attack, and found the limbs completelypar- alytic, with frequent spasmodic contractions. Nothing was to be dis- covered 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 affection, her elder sister, aged 16, who had been rather delicate, and at times hysterical, was observed to walk awkwardly; and, in a few day7s, 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 abdomen, and the heels to the buttocks. In this manner she lay during 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 in- to their contracted condition. If an attempt was made to extend them, great and continued force was required, until they were brought nearly to the extended 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 sudden and painful jerk thrown back into their contracted state. This young lady had also occasional spasmodic affections ofthe arms, and ofthe mus- cles ofthe neck; but these were transient, and there was no diminu- tion of muscular power in the arms. There was considerable uneasi- ness 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 anti- 288 PATHOLOGY OF THE SPINAL CORD. spasmodics, topical bleeding and repeated blistering on the spine. In the elder ofthe two, one ofthe blisters led to the formation of a large and troublesome carbuncle on the spine, and this seemed to accele- rate th;j cure. I do not know whether the following case ought to be referred to this class; it excited my attention, as a very remarkable affection at the time when it occurred, and I have not seen another exactly re- sembling 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 extremi- ties, 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 diminution of muscular power. He could walk a considerable distance, though he did so with a feeling of insecurity and unsteadiness; but he could not in the smallest degree perform such 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 con- tinued in the 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, con- siderably different from those which I have now described. I receiv- ed from my friend, the late Dr. Monteith of Glasgow, a very inter- esting 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 headache, accompanied by a sense of tension in the head, and strong throbbing in the carotids, temporal arteries, and throughout the head; the pulse 120. Large and repeated bloodletting was employed for the first ten or twelvze 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 headache was followed by an increase of irritation, pain and retraction of the limbs. The headache 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 bloodletting, and large doses of laudanum, of which she some- times took 500 drops in the course of a night. Mercury appeared Concluding observations. 289 at one time to be productive of some benefit; the effect, however, 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 irrita- tion as to bear 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 headache 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 attacks the pulse became very strong and jarring, and the face flushed and swelled; and the only relief she obtained vvas 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 headache, 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 ra- ther increased, and she was confined to bed in a state of extreme ex- haustion, and suffering from constant and intense headache. Soon after, she first complained 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 accompanied by such increased sensibility that she could not bear the weight of the bed-clothes upon them, and the slightest touch with the finger made her scream. There vvas 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. F,rom the commencement 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 disease could be discovered on exmination or by pressure. She now became much emaciated, pale and debilitated ; the headache was rather relieved, but the limbs con- tinued 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 end 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, 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 37 190 PATHOLOGY OF THE SPINAL CORD. which gave me more the impression of deep-seated and hopeless dis- ease. The history of these cases conveys a more distinct impression 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 pulsation 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 affect- ed, but not so severely as the lower extremities. This lady vvas con- fined to bed for two years, and then recovered perfect health, which she had enjoyed for five years at the time when I received this ac- count. In another there was such incessant vomiting that she retain- ed nothing in the form of food, drink, or medicine, for six weeks. In this case the vision was also very much impaired, and twice sus- pended 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 bene- fit was experienced from bloodletting, very large opiates, and warm bath; but, upon the whole, the diesase seemed gradually to wear itself out, without any mode of treatment having a sensible effect in arrest- ing 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 recom- mended; 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 attending it in his observation, such as attacks of dyspnoea, resembling croup, tempo- rary loss of speech, and of the power of swallowing, and temporary aberration of mind. He agrees 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 medi- cine, beyond 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 Irritations 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 CONCLUDING OBSERVATIONS. 291 recollection, with convulsive motions of the arms, grinding of the teeth, and violent palpitations of the heart. These attacks continued to re- cur at uncertain periods; and, during the intervals, he did not entirely recover from the effects of them. He continued depressed and inca- pable 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 employ- ed 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 affusion. I have frequently seen in young females a slighter affection, in which there was pain referred to various parts of the spine, sometimes chief- ly to the lower part of it, and sometimes extending upwards and down- wards 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 blistering, without benefit; and 1 have generally found the most effect- ual 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, whe- ther this conveys any definite notion, or whether it is not to be con- sidered as a gratuitous principle, assumed so as to answer to the phe- nomena, rather than deduced from observation. When w7e 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 con- sider this as directing our attention to an important seat of disease; but 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 gentle- man, about whom I was consulted some time ago, bad a severe and long-continued attack of nephralgia, 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 quan- tity. In the course of the complaint, and about the time when the violent pain, which was in the region of the left kidney, vvas beginning to subside, he vvas affected with difficulty of swallowing, a sense of constriction in the oesophagus and the pit of the stomach, and spas- modic 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 affec- tions are met with; and in these, one of the most remarkable features of them, is the connexion which they have, even in their most aggra- 292 PATHOLOGY OF THE SPINAL CORD. vated forms, with the state of menstruation. The following case will illustrate this in a striking manner, and at the same time exemplify some ofthe various forms which are assumed by these singular affec- tions. 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 sometime 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 characters of chorea. After another interval of sev- eral months, she became liable to attacks of blindness, which were oc- casioned 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 tem- ples. With these symptoms the two first years of her illness passed. In the third year, she was affected with convulsive action 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 de- scribe. These were much 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 was difficulty of deglutition, so that attempts to swallow produced spasms resembling tetanus. At other times, after lying for a consid- erable 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 con- tinued entire, 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 ofthe back and the neck, producing a constant rotary motion of the head. This sometimes continued without interruption night and day for several weeks together, and if the bead or neck were touched the motion was increased to a most extraordinary degree of rapidity Du- ring the attacks, she could not sleep, except in the sitting posture the motion continuing during this imperfect sleep, though in a more mod- erate degree; but if she happened to slip down, so that her head touch- ed the pillow, she instantly awoke with a severe convulsive start and the motion was increased to the greatest degree of rapidity ThesP exteOnTori0Worei2oeVed * T^ bulCUPPinS on the temples to the extent of 10 or 12 ounces, when the affection ceased in an instant with a general convulsive start of the whole body. She was then im- CONCLUDING OBSERVATIONS. 293 mediately well, got up, and was able to walk about in good health for several weeks,—when the same symptoms returned, and required a repition of the same treatment. Sometimes, from the violence of the motion ofthe 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 moderated, as to allow it to be applied on the tem- ple, 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 ofthe whole body: when it subsided gradually, as un- der the influence of large bleeding, it returned as soon as the faintness from the bleeding was removed. The affection went on in this manner, with intervals of tolerable health of a few weeks duration, for about four years, besides the two years formerly mentioned. The longest interval was one of about three months, but even during these intervals various convulsive mo- tions were excited by slight causes. Menstruation was all along ex- tremely irregular and very scanty, and the bowels were torpid. She was of a pale and bloodless aspect from the frequent bleedings, but not reduced 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 par- oxysm of the rotatory motion ofthe head; when it was determined to allow the attack to take its course, and to direct our attention en- tirely to the menstruation. With this view she began to take three grains of sulphate of iron three times a day, with two grains of Bar- badoes aloes,—the aloes being afterwards diminished according to the state of the bowels. She went on with this for nearly three weeks; the convulsive motion of the head continuing without inter- mission 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 an- other form of this affection. If we were required to give a name to this modification, we could probably call it nothing but a very aggra- vated form of hysteria. Case CL1X.—A young lady, aged 15, in October 1828, was thrown from a horse, but did not appear to sustain any injury except a contusion ofthe arm, and she did not complain of any thing else for 294 PATHOLOGY OF THE SPINAL CORD. 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, talk- ing in a wild extravagant manner, and appearing totally unconscious of the presence of 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 treat- ment 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 fort- night, and was succeeded b}7 another fortnight of convalescence, when the affection was re-produced by the patient being told of the illness of a near relative. During the paroxysms she generally complained of intense head- ache, which was chiefly referred to the occiput; the pulse varied from 90 to 120; the tongue vvas white; the bowels torpid and motions un- healthy; her nights were sleepless. After the third ofthe paroxysms now mentioned her convalescence 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, wiih flushing. This continued several days, and vvas succeeded by a state resembling catalepsy; the eyes being continually fixed in one direction 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 swallowing; after several days more she began to speak, after having spoken none for 13 days, and then went on gradually improving for some weeks. The comatose stale then returned, and vvas 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 sud- denly 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 without any recollection of the attack, or of the circumstance which had excited it. In the middle of March she became again in- coherent and unmanageble, and this alternated with the cataleptic at- tacks till the middle of April, when a new set of symptoms commen- ced. 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 CONCLUDING OBSERVATIONS. 295 distorted; the hands clenched and firmly pressed on each side ofthe trachea. During these attacks respiration seemed nearly suspended for some minutes, and in her convulsive efforts to breathe, she some- times 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 succeeded by the slighter cataleptic attacks ex- cited by various slight causes. It was at this period ofthe 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 par- oxysms; 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 in- sensible 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 recurrence of it before she returned home. The slighter paroxysms were still ex- cited by the sight of a stranger, or by any cause of mental agitation. During these her body became motionless, but without losing her bal- ance, 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 some- times relaxed, 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 continue i to play with perfect correctness, but repeating a certain part of a tune, and never going on beyond a particular point. This she sometimes continued to do for ten minutes at a time, during which period she was totally unconscious of any7 external impression. On one occasion she vvas 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 it five or six times in the most correct manner; but when she recovered from the attack, she could not play it without the book. The ca- tamenia, 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 removed to a distant part of the country, and I have heard of her only occasionally. But I un- derstand 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 con- 296 PATHOLOGY OF THE SPINAL CORD. vey any idea of them by a general description. 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 repeatedly 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 unfre- quently by the striking of a clock. Her mind was quite entire, but she had no control over the affection, except that during the paroxysms she could change the sound when she was requested to do so, and. substitute any other word that was suggested to her. The affection 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 purgatives. For a considerable time after her recovery, though she was not at all affected by her dis- order 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 parox- ysms of rapid and laborious breathing with a loud shrill sound, and the appearance of the utmost distress, as in the most aggravated form of croup. They came on without any warning, when she vvas in perfect health, and if not relieved, continued for days together. They were relieved by nothing but bloodletting, but in several instan- ces, 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 gradually after continuing to recur in this manner for more than a year. A case of much interest has been related by Dr. Follot 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 ofthe lower extremities; and in the following month, the limbs be- came forcibly bent, so that the heels touched the buttocks, and every attempt to extend them produced the most acute suffering. These symptoms continued five days, and then subsided; but they were re- newed at the same period in the succeeding month, and subsided af- ter the same duration, but left a degree of paraplegia. The attacks were afterwards moderated by repeated topical bleeding, vapor 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, toI. i. APPENDIX TO PA R T FOURTH. OUTLINE "OV THE DISEASES OF NERVES. Nearly allied to the pathology of the spinal cord, is another subject of very great interest, the pathology of nerves. This subject is en- tirely in its infancy, but the investigation seems to promise very inter- esting results. From what we already 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 substance or in their membranes, arid are probably the source of several diseases which are at present involved in-much obscurity. In as far as this subject has hitherto been investigated, the following may be considered as the principal idiopathic diseases of nerves which have been observed. 1. A uniform dark red color of the nervous substance, occupying a defined space, perhaps an inch or two in extent. This was observ- ed 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 followed by palsy. In a similar affection of the right sciatic nerve, accompanied by palsy of the limb, he .found a dis- eased portion of nerve enveloped in a quantity of gangrenous cellular tissue. In another case he found a diseased portion of the crural nerve, which was an inch and a half in extent, enlarged to about double its natural size. This portion vvas of a violet red color, and strewed throughout with small ecchymoses each about the size of a pin's head. • Revue Medicale, Juin, 1814. 38 298 outline of the diseases of nerves. IL Serous or bloody effusion within the sheath of the nerve, pene- trans the substance of the nerve, and separating its fibres from each others This appearance was found by Martinet 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 abdomen, 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 appearance 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 color. V. Ulceration ofthe 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 ampu- tation necessary, and, in many parts ofthe limb, the nerves were found much enlarged..f.. VI. Small tumors attached to nerves, and productive of violent symptoms, have been described by various writers. In a remarka- ble case by Portal, a woman was cured of .epilepsy by the removal of one of these tumors;.from the thumb. The slightest pressureu pon 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 affections 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 tubercles 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 di- aphragmatic nerve. The man had been asthmatic, but he had also slight emphysema of the lungs.. * Descot, Sur Ies Affection Locales des Nerfa. t Swan on the Local Affections of the Nerve*. OUTLINE CF THE DISEASES OF NER.VES. 2S3 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 di- viding the nerve" above and below. On cutting into it, an expansion of the siibstance of the nerve seemed to form, an imperfect cyst, which contained a medulary and fatty matter, and the filaments of the nerves were continued over it. There had been great numbness and loss of power ofthe arm, but it gradually improved after the operation.!. VII. Nerves-have been found both very much enlarged and very much diminished in size ; and they have been in "a fevy h stances found with the nervous substance destroyed, the membrane at the part forming an empty canal. But these points- have not yet been suffi- ciently investigated. . . • .. Few opportunities have as yet occurred of- ascertaining, the condi- tion ofthe nerve in those Interesting eases-of local paralysis, which have been so beautifully illustrated by. Sir -Charles Bell, and his la- mented, friend the late Mr, Shaw... It is.probable that there is either an inflammatory action in the nerve itself, or its coverings ;. or that the nerve is affected by disease of some of the parts through which it passes. . The only casein which I have had an opportunity of exam- ining the parts, since- I was acquainted4.with the discoveries of Gir Charles Bsll, 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 orbi- cularis of the left eye. She had afterwards considerable indistinct- ness 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 tunior was felt-under the ear, deeply seated betwixt the angle of the jaw and the mastoid process..-On dissection no discace 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-color; arid, when cut across, it discharged thin puriform sanious 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 structure surrounding the .nerve; but I could not discover any deviation from the healthy structure'in* the -nerve itself. I thought it vvas diminished 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 auditory portion of the tem- poral bone, a part of the portio dura was entirely destroyed; and iq a case by Billard, connected with an unhealthy abscess of the parotid * Pring on the Nervous System. [ t For a very foil 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 of Edinburgh, vol. ii. 300 OUTLINE OF THE DISEASES OF NERVES. gland, the course of several of the nervous branches was interrupted by destruction of part of their substance. An epileptic patient, men- tioned 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 ofthe discoveries of Sir Charles Bell is, that there may be paralysis ofthe 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 depends upon a disease limited to the portio dura of the 7th 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 expo- sure to a current of cold air, as when a person has sat long, or has slept, opposite to an open window, or has sat in a carriage with a cold wind blowing on one side of his head. It is to be treated chiefly by local remedies, 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 sev- eral 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 formida- ble modification of it which depends upon disease of the temporal bone. The character by which these cases are distinguished from paraly- sis depending upon disease of the brain, consists chiefly in the sensi- bility 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 peculiarities arise from the remarkable fact demonstrated by Sir Charles Bell,-Mr. Shaw, Mr. Mayo, and others, that the portio 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 muse es 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 in regard to the paralysis of the eye-lids which occurs in these cases, namely,-that is the inability to shut the eye that arises from the affection of the portio dura of the 7th. The dropping of the upper eye-lid and in, bihty to raise it, is a disease entirely of a different nature it depends" upon an affection ofthe 3d nerve, and consequently gives more reason to suspect disease within the head. S reason OUTLINE OF THE DISEASES OF NERVES. £01 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 paralysis without diminution of sen- sation, the disease depends upon an affection of the portio dura alone, and may be entirely 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 ofthe temporal bone, it may come io be attend- ed with danger by inflammatory action spreading inwards to the dura mater or brain. There is another modification also which requires to be watched with anxiety, namely, when the affection is accom- panied with deafness; as this gives reason to believe that both portions of the 7th nerve are affected, and consequently to [suspect an internal 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 hadj 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 gradually lost the hearing of that ear, and about the same time the right side of his face became paralytic without any diminu- tion of sensibility, and the action of the masseter and temporal mus- cles was unimpaired. Without any farther change of these complaints he died of phthisis in April 1829. The petrous portion of the tem- poral bone vvas found most extensively destroyed, leaving an exca- vation which contained fetid purulent matter and portions of dead bone. The 7th nerve was traced from within to the margin of this excava- tion 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 patient suffered greatly from dyspnoea, during the severity of which the alae 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 proba- bly have terminated 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 ofthe year 1829. The patient, a man of 30, was seized in the beginning of 1825 with acute pain, referred to a 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 grad- ually recovered, and vvas 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 deaf- ness was permanent; the pain and squinting subsided.after three or 302 OUTLINE OF THE DISEASES OF NERVES. four months;.but returned after two or three months more, accompa- nied by inability to close the eye-lids of the left side, and considera- ble 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 hadnow 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 inwards towards the nose, and frequent spasmodic twitches of the jaw, by which it was drawn to the fight side; and he died in a state of coma in February 1829. On inspection there was found im- mediately behind the left temporal 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, apd the left side of the tentorium vvas also very much thickened, and present- ed on its inferior surface several tubercular elevations. 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-mollisof the 7th was, for a few lines previous to its enter- ance into the meatus,, of a' reddish-grey color, and nearly gelatinous consistence; the portio dura seemed smaller than usual. In the sub- stance of the right hemisphere, nearly oh a level with the ventricle, there was a tubercle the size of a French beari; and there vvas a small cyst in the right corpus striatum. . In the posterior cornu of the right ventricle, there vvas a peculiar appearance, as if a portion of it had been obliterated by adhesion, cutting off a very small cavity about the size of a lemon-seed, which communicated'by a narrow opening with the ventricle, arid presented at each extremity a yellowish line or raphe resembling a cicatrix. No appearance of disease could be detected iu the contents of the spinal canal. This case is one of great interest, besides the point which it is here introduced to illustrate. In particular, it 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 feature of the case at various periods, appears to have been connected with inflammation of a defined portion of the membrane in that situation. The remarkable affection of the func- tions ofthe 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 abducter muscle, we trace to the sixth nerve being involved in the disease. No cause appears to which we can refer the paraplegia, except the disease ofthe tentorium, no morbid appearance having been discover- ed in the spinal cord or its membranes after the most careful exam- ination. I have formerly referred to certain difficulties in the pathol- ogy of paraplegia, and the obscurity attending those cases in which it OUTLINE OF THE DISEASES OF NERVES. 303 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 thij enquiry. The functions of the 5th nerve, as has been mentioned, appear to be, to give sensation to all the parts about the face, and motion to the muscles of the jaw; and a variety of singular phenomena arise from af- fections of this nerve, or particular branches of it. - Thus, in the or- gans 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 particular branch of the 5th, as in a strik- ing 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 bad lost entirely the sensation of 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 sloughing in parts which have lost their sensibility,-—particularly in the eye. A very.instruc- tive case of this kind occurred to *my friend.-Dr. Alison. The pa- tient had loss of common sensation on the leftside of the face, the left nostril, and-left side ofthe tongue, with insensibilily of the ball of the eye, and occasional 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 form- ed 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 paralytic, and felt quite flaccid when the patient chewed or clenched the jaws, but the motion of the muscles ofthe 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 headache 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 ofthe brain. The 5th nerve of the left side, on being traced backwards from the • See page 196. t Sir Charles Bell's Lectures, as reported in the Medical Gazette,vol i. 804 OUTLINE OF THE DISEASES OF NERVES. ganglion, vvas found, close to the ganglion, to be of a very dense tex- ture, 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 ihe 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 symptoms, and has since continued, liable to severe headache and epileptic fits. The loss of sensibility continued about six months. 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 mem- brane ofthe left nostril was always of a deep red color, and there were frequent discharges of blood from it. The conjunctiva of the left eye became deeply injected; this was followed by opacity and ul- ceration 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 paralytic parts of the face. The patient had been long affected with headache, and at last died two months after the commencement ofthe paralytic symptoms. A tumor was found the left side of the tuber annulare, which com- pressed 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 color, and extended into the left crus cerebelli. To affections of the nerves may probably7 be referred certain ob- scure and severe disorders of a nervous kind, some of which have su- pervened 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 ofthe arm, and loss ofthe voluntary power of the wrist and fingers. The affection resisted every mode of treatment for two years, and then got speedily well after the application ofthe actual cautery to the cicatrix ofthe original wound. In a lady, mentioned by Mr. Swan,! a slight wound on the thumb was followed by numbness, pain, con- vulsive 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 en- tirely free from uneasiness at the end of seven years. A very violent case of the same kind, described by Wardrop,§ was cured after twelve * Medical Gazette, vol. i. t Jour, de Med. vol. x. X Swan on Local Affections of Nerves § Med. Jur. Chir.Trans. vol. iii. OUTLINE OF THE DISEASES OF NERVES. 305 months by amputation of the finger. In a similar case by Larry, which followed a wound, a portion ofthe nerve was removed, without complete success, though the disease was very much alleviated. In a singular case by SirEverard Home,* a gentleman received a violent sprain of his thumb, by the weight of his body being thrown upon it, in saving himself 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 ofthe 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 insensibilily. A nerve in this case was divided without success. The tourniquet lost its effect in arresting tile spasms, and he died suddenly after three months, but there was no examination of the body. In the Medical and Physical Journal, Mr. Jeffries has described a remarkable caseof a violent neuralgia of the face, which was cured by the extraction of a small fragment of china, which had been lodg- ing there for fourteen years; and M. Descot mentions a case in which a very severe affection of ten years standing was removed by the ex- traction of a carious tooth. A young lady, mentioned by Mr. Pear- son, was seized, without any obvious cause, with pain in the thumb, accompanied by a morbid sensibilny of the part; the affection gradu- ally spread over the arm, and was accompanied by loss of nearly the whole muscular power ofthe extremity, with morbid sensibility ofthe integuments, and a strong contraction of the-fingers, so that the points ofthe nails were forcibly pressed against the palm ofthe hand. The fingers were not under the control of the will, and every attempt made to extend them was accompanied by insupportable pain. The joint ofthe 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 vvas inexpressibly distressing. After some time the other arm was slightly affected in the same man- ner, and she had likewise pain and great debility of both the lower ex- tremities. After this affection had continued about a year, it got well under the use of a liniment composed of olive oil, turpentine, and sul- phuric acid. This produced most severe erysipelatous inflammation, which, beginning upon the affected arm, extended afterwards over the whole body.f 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 twenty years since I first saw a girl, aged at that lime • Phil. Trans. 1801. t Mod. Chirurg. Trans, vol. viii. 39 306 OUTLINE OF THE DISEASES OF NERVES. about 18 months, and previously enjoying excellent health. She had been left for some time sitting upon damp grass, and was immediately 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 of 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 op- posite extremity, and several inches shorter. All the joints are re- markably relaxed, and the muscles flaccid; but there is no other ap- pearance of disease in any part of it, or in the spine. Sometime ago I was consulted about a young man, aged 14, who had nearly lost the muscular power ofthe upper part of both his arms, accompanied by a most remarkable diminution of substance of the principal muscles. The deltoid and biceps are reduced to the appearance of mere mem- branes, and the same affection extends, in rather a less degree, to the muscles upon the scapula; the muscles upon the forearm, 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 can only be referred to the same subject, 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 I was consulted about a singular disease of this nature which occurred in par- oxysms, and affected in the same manner two individuals of one fami- ly, a young lady of 25, and a young man of 22. The lady described the attack in the following manner. She was at first affected with blindness of the right eye, which came on gradually 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 extending very gradually over the whole hand and arm, producing 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 ofthe head, and from this it seemed to spread down- wards towards the stomach. When it reached the side of the head she became oppressed and partially confused, answered questions slow- ly 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 headache, which continued for several hours, and left her for a day or two feeble and languid. The progress ofthe feeling of numb- ness from the little finger to the stomach, sometimes occupied seve- ral hours, and the common duration ofthe whole paroxysm was about OUTLINE OF THE DISEASES OF NERVES. 307 twenty-four hours. The frequency of its occurrence varied from a few days to several 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 twenty two 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 be- tween the attacks, enjoyed perfect health. When he felt the com- mencement of the attack, he hastily brought to a conclusion any busi- ness 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 af- fairs of his department; then walked home, went to bed, and soon af- ter became insensible. Next day he was inJiis 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 purga- tives, followed by a course of sulphate of quinine, combined with small quantities of rhubarb. In a farther report received in 1829, Dr. Gib- son informed me that the affection had continued, but that the attacks had been less frequent and less severe; arid that, on several occasions, they seemed to have been lessened in violence and shortened in dura- tion by emetics. In 1834 I learnt that the young man had entirely recovered; but that the lady had died of consumption in 1832, and had continued liable to occasional attacks of her peculiar headache al- most 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 inflammation of the great sympathetic nerve; and to this source he.refers many obscure diseases, such as, violent hysterical affections, sympathetic affections ofthe heart, spas- modic cough, colica pictonum, angina pectoris, and many obscure af- fections of the stomach and bowels. In the same manner, he explains the fatal effects which are produced by blows upon the stomach, and the severe symptoms, both in the head and in the general system, which often arise from worms, and from other disorders of the bow7els. In a lady who died of urgent vomiting, with burning pain in the spine and in the right hypochondrium, he found the semilunar ganglion m 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 ep- igastrium, 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 appearances, consisting of mere change of color of parts, without any of the aetual results or » De Nervi Sympathetic Tabrica, usu, et Morbis- 308 OUTLINE OF THE DISEASES OF NERVES. 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 internal nerves which may be the source of im- portant morbid phenomena. Descot exposed the par vagum upon the neck of a dog, and bruised it on both sides slightly with a pair of pin- cers; the wound healed favorably, but the animal was affected with general tremors, difficult and laborious breathing, vomiting, great de- bility and wasting. The vomiting subsided, and the other symptoms were diminished, but he had not recovered a natural state of his breath- ing, when he was killed at the end of three weeks. The internal or- gans were «11 healthy. The nerve on the left side, where the injury had been inflicted, appeared slightly increased in size, and was of a yellowish color; and that on the right side appeared more decidedly enlarged, highly injected, and adhering to the neighboring parts. 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—Long-continued headache, terminating at last by coma or by gradual exhaustion. (See page 230.) Symptoms. Case I.—A woman of 35—fixed pain in the back of the head—walk tremutous and unsteady, like a person balancing a burden on the head—much throbbing in the head—hysterical symptoms. Remark- able" remission of all the spmptoms after the formation of an abscess hi the ax- illa; but the pain returned when it healed, and increased to tremendous severity, and with remarkable remissions. From two o'clock in the morning till two in the after- noon she was in the greatest agony, lying with her eyes closed—the eye-brows con- racted—the hands clenched—and the head immoveable in one position—unable to bear the least noise, or to move a muscle. Af- ter two P. M. the symptoms gradually re- mitted—she took food, and about nine fell asleep, and slept till two, when the parox- ysm recurred. As the disease advanced, the interval became shorter, and for a fort- night before her death the pain was con- stant—sense entire to the last—palsy of the left leg for three days before death —duration ofthe case fourteen months. Case II.—A man, aged 40—violent 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 salivation, but always recurred with great violence, and was re- ferred to a single point at the junction of the temporal and occipital bones—frequent Morbid Appearances. A tumor at the base of the cerebellum, growing from both lobes of it, and descend- ing within the dura mater into the spinal canal, as low as the sixth spinal nerve. It was soft like fest;il brain, and seemed to grow out of the interior ofthe cerebellum. As it lay along the spinal cord, it rested upon the origin of the nerves, but did not involve them in its substance. Dr. Latham Med. and Phys. Jour. July, 1826. In the left lobe of the cerebellum, a tu- mor 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 properties of albumen, which grated under the knife. It was en- closed in a cavity which also contained a tough glutinous matter, and the surround- ing substance was like rancid bacon 310 SUPPLEMENT TO PART III. Symptoms. vomiting—impaired vision. Died sudden- ly in one of the attacks of pain—duration ofthe complaint about a year. Case III.—A young man of 20—vio- lent pain of the forehead;—it occurred in paroxysms which 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 convulsion. Case IV.—A man of 50—constant pain of forehead, with frequent vomiting. Oth- er functions healthy. Coma for three days before death. Death in three months by gradual exhaustion. Case V.—A man, aged 55—lancinating pain in the right side of the head'—aggra- vated at intervals. After two months co- mi and death. Case VI—A boy of 14—severe head- ache for two months—then convulsion, followed by coma and death on the 8th day. Case VII.—A man, aged 35—violent headache, which was sometimes so severe as to oblige him to remain for a considera- ble time in one posture, incapable of the least motion—consumptive symptoms— death after seven months in a state of com- plete marasmus. Case VIII.—Man of 58—liable for 15 years to attacks of acute pain in the right temple, extending over the right side of the head and face—first attack continued three weeks—and it afterwards returned in paroxysms of very uncertain duration, and at very irregular intervals. After fif- teen years, a more severe attack, which continued two months and ended in coma and death. For some days before death, had palsy ofthe left side, and of the right eyelid. Case IX—An officer, aged 33—slight pain and confusion of the head with im- paired appetite. After ten weeks, nau- Morbid Appearances. Pi of. JVasse App. to Germ. Trans- of Dr. Abercrombie's Papers o>i the Brain. A tumor of the size of a pigeon's egg, hard in the centre, and externally soft, in the substance of the cerebellum, other parts healthy. Pla>\que Biblioth. HI. 348. A tumor two inches long arising frorn the cella Turcica, covered by the dura ma- ter. Ventricles distended with seram. Communicated by Mr. William Brown. A mass as hard as scirrhus, four inches long, and between two and three broad, in the substance of the right hemisphere, on the outside of the thalamus. Internally it contained small cells full of gelatinous mat- ter. Bouillaud Traile del Encephalite. A tumor the size of a walnut of a rare color and a fatty consistence behind 'the posterior part of the medulla oblongata; another smaller in the left lobe of the ce- rebullum. Serous effusion—diseased mes- enteric glands—ulceration of the small in- testines. Merat Journ. de Mel torn. X. Three ounces of fluid in the ventricles, a firm tumor the size of a pigeon's egg in the upper and middle part of the right hemis- phere, enclosed in a reddish sac, internally of a yellowish color. A larger tumor of the same appearance in the left lobe of the cerebellum—extensive disease of the tho- rax and abdomen Merat, ut supra. On the outside of the right thalamus and on a level with it, a tumor in the sub- stance of the brain of a reddish-grey co- lor—four fingers breidth in length, and two or three in breadth, partly hard, and partly in cysts, containing a gelatinous matter. Andral Jour, de Phyt Three ounces of fluid in the ventricles— in the seat of the pineal gland, a little to right side, a tumor the size of a nutmeg— CASES OF ORGANIC DISEASES OF THE BRAIN. 811 Symptoms. sea and pain in the eye-balls. He was then wounded in the head—lost much blood, and the bone exfoliated, and he was much better for more than a year. Then headache — watchfulness — flushing— and ophthalmia. Recovered after three months, but was never free from headache. It gra- dually increased ; was sometimes referred to a spot on the occiput, and sometimes through the wholo head. Was much ag- gravated by motion, which produced a painful jarring in his head, and much in- creased by going to stool—pain at last ex- cruciating, 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—severe shooting pain in the occiput—at first alle- viated towards evening—afterwards unre- mitted. Constant sickness, and afterwards vorfiiling of every thing taken. Death from gradual exhaustion in four months. Morbid Appearance. internally it was like cheese, but organiz- ed. Ramollissement of the cerebellum. Sir G. Blanc, Trans, of a Soc. vol. ii- A soft tubercular mass the size of a ha- zel-nut in the posterior lobe of both hemis- pheres—left lobe of the cerebellum almost destroyed by the softening of a similar tu- mor occupying its interior—substance, of the cerebellum around it indurated. 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 present little variety in the phenomena. In a case by Willis, there was a tumor three inches broad, adhering to the membranes at the side of the third sinus; and in one by Saviard there was, under the junction of the larnbdoidal 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 discharged a little pus. In a lady mentioned by Borellus there was, near the tor- cular, a hard rough irregular mass of a stony consistence, 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 intense headache, which left him no interval of ease day or night. See also the cases formerly described under the head of tubercular diseases of the brain,* particularly Cases LXXXIII, LXXXV, and XC, which exhibit examples of organic diseases, with remarkable remissions of the pain. SECTION II. Second Class.—Headache, affections of the senses, speech, or intellect. Symptoms. Morbid Appearances. Case XL—A man, aged 42—after ex- At the anterior part of the right hemis- posure to the sun by walking in a procession phere, a scirrhous mass the size of a nut. 312 SUPPLEMENT to PART III. Symptoms. Morbid Apppearances. without his hat, was seized with headache, surrounded by extensive ramollissement which became intermittent, and was treat- of the cerebral substance—thalami sound — ed by bark. After six weeks it ceased, but optic nerves shrivelled. left amaurosis. Then followed fever and Cruvielhier Nov. Bib. De Med. JVoo. death. 1825. Case XII.—A man, aged 47—headache and weight in the head, increased by stoop- ing. Began in May, 1816, and increased gradually, notwithstanding copious evacua- tions. In August his sight began to dimm- ish, with giddiness; in September, could only see objects in a very strong light; in December, perfect blindness—pain still constant and severe. In the middle of January stupor and forgetfulness, and died comatose on the 31st. 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 likewise entering into its substance above. Internally it was firm, and resembled the structure of rhe kidney—fourj ounces* of fluid in the ventricles. Author's JKotes. Case XIH.—An officer who had seen much service—severe headache which sub- sided, and left a feeling of tightness across the forehead. After six or eight months, blindess 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 disordered stomach, and frequent in- clination to vomit- Death from coma after two years. _ Case XIV.—A man, aged 30—excru- ciating headache, which commenced after hard working in a hay-field—chiefly refer- red to the forehead, from which it extended over the left ear, but sometimes affected the right side ofthe bead also, and occasionally the neck—more severe in the night. After six or seven weeks blindness. At the end of two months an apoplectic attack, and death in two days. Four ounces of fluid in the ventricles; a tumor, the size of a hen egg, containing a thick puruleut fluid, under the anterior part of the brain, and interposed betwixt the optic nerves, which were much separated by it from each other. Below it was at- tached to the pituitary gland, which was very soft, and enlarged to five or six times its natural size. Med. Trans, vol. v. Dr. Powel. A tumor, the size of a large walnut, pro- jected from the lower part of the anterior lobe of the left hemisphere. Internally it resembled an absorbent gland. The great- er part of the medullary substance of the left hemisphere was reduced to a soft pulpy state, and was of a light brown color. Med. Trans, vol. v. Dr. Powel. ?n, l^.e .otner cases of .this class the symptoms are nearly similar,— fixed'pain in the head and gradual loss of sight,—the intellect being fre- quently affected in' the advanced stages, and frequently the speech impaired. A case has been already described, in which there was blindness of one eye and loss of speech, in connection with a cyst containing albuminous matter in the posterior part of the left hemis- phere—(See Case XCI, page 174.) 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 cere- bellum. In this case there were both blindness and deafness, and it was fatal suddenly hy 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 CASES 0i' ORGANIC DISEASES OF THE BRAIN. 313 sight and speech, and loss of the memory of names, there was a tumor the size of a large nut in the anterior part ofthe left hemisphere. SECTION III. Third Class.—Headache—affections of the senses a-nd convulsions. Symptoms. Case XV.—A girl, aged 11—long lia- ble to headache, with weakness of sight, and a peculiar tenderness of the integu- ments of the head. In autumn 1314, she received an injury on the forehead from a fall, and from that time suffered much from headache, with frequent epistaxis. In the end of December the headache 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 fbr 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- ache increased, with impatience of light and sound—squinting, gradual failure of sight, at last blindness in July. She died in October, her intellect having continued unimpaired; remarkable acuteness of hear- ting, and intolerance of sound continued to the last. Cask XVII.—A servant girl long sub- ject to headache, which, in her 19th year, became very severe, and occurred periodi- cally, generally once in four weeks and sometimes oftener. Tn her 21st year, the headache became more violent and perma- nent, with frequent vomiting, and occa- sional fits of insensibility. She had then attacks of double vision, and afterwards convulsions, which returned at first in five Morbid Appearances. A tumor the size of a walnut rested on t, the cella Turcica, and compressed the - junction of the optic nerves. It was com- 3 posed of a medullary substance of a yel- i lowish color, and was covered by a thin i and delicate membrane. ) Communicated by Dr. Hay Throughout the substance of both hemis- pheres, and in the corpora striata, there were numerous tubercles the size of peas. They were externally hard, and internally contained a small cavity full of a thick greenish fluid Twenty-one of them were collected—substance of the brain healthy —corpora striata considerably softened. Prof. .Vc/.w, vt supra. Case XVI—A young man of 15—deep seated pain in the head, and after six months inarticulate speech. Three at- tacks of convulsion, each of ten or fifteen minutes duration; the last left palsy ofthe right side, which disappeared next day. Died comatose in another month, having had repeated convulsive attacks, intense headache, impatience of light, afterwards dilatation of the pupils, deafness, palsy of the eyelids, very difficult articulation, and some delirium. Four ounces of fluid in the ventricles; on the left side of the pons Varolii, a hard tumor the size of a bean; surrounding sub- stance softened, approaching to suppura- tion. Coindet sur VHydrenceph. p, 98. 314 SUPPLEMENT TO PART III. Symptoms. or six days, and afterwards every second or third day,. About three months after the commencement of the convulsions, she was one morning found dead in bed. Case XVIII.—A woman, aged 19— Headache, vertigo, effusion of the eyes; paroxysms, in which she fell down insensi- ble,, without convulsien. They attacked her once in three weeks, and at each time there were two paroxysms at the distance of twelve hours; after eight or nine months, these attacks increased in severity. She» had then loss of hearing, sight, and smell, and her speech and deglutition were much impaired. Soon after this died apoplectic. Case XIX.—A man, aged 24,—se- vere headache—whatehfulness and imbe- cility of the head—blindness of the left eye, and after a month of the right. Con- vulsive paroxysms which continued to recur for six months; they then seased, and he died of pectoral complaints. Case XX.—A child of 4 years—unable to walk—articulation very imperfect—in- telligence very deficient—deglutition very difficult, liquids swallowed often returning by the mouth and' nose—difficult respiration and frequent convulsions—but vyas full in flesh—had been in this state about a yenr— died in six months more. Case XXI—A woman, aged 23—After suppressed menstruation, violent headache, impaired vision, and after some time blind- ness. Repeated convulsive attacks; after one of which she lost her speech for two days. Intellect entire. Died comatose af- ter four months. Case XXII.—A lady, aged 40, of a scrofulous habit—gradual failure of mem- ory, sight and hearing; inarticulate speech; epileptic paroxysms, at first once in the fort- night, afterwards more frequent—her gait feeble and tottering—died 'n siX months. A year befere her death, she had been much stunned by a fall down a stair. Morbid Appearances. Embedded in the substance of the right hemisphere, there was an hydatid, three inches long, and two broad, and very vas- cular. Brain in other respects healthy- Yelloly, Med. Chir. Tram. vol. ii. Extensive disease of the- lungs; mncfc effusion in the brain; in the substance of the left hemisphere, a tumor larger than an egg, weighing fourteen drams; it was covered by a fine sac, and internally was while, firm and uniform, resembling coagu- lated albumen, but harder. Felix Plat ervs, Lib I. 108. Corpora oblivaria, cms cerebelli, and tu- hercula mammillaria in a state of cartilagin- ous hardness; other parts sound. Author's JVotes. On the surface of the right hemisphere there were three hardened spots, each an inch in diameter. They were the surfaces of tubercular masses, which extended into the medullary substance of the brain. There was a similar tubercle in the sub- stance ofthe hemispherc,*and one smallen in the surface ofthe left hemisphere. Slight effusiou in the ventricles. Powel, Med. Trans. V. A tumor, the size of a small orange, Jay on the pars petrosa of the left temporal bone, inclining io the opposite side, and producing great depression in the substance ofthe brain; the seventh pair of nerves, and the branches of the fifth pair were com- pressed and stretched by the tumor. Inter- nally it consisted of a soft uniform sub- stance resembling the cineritious matter of the brain. Communicated by Dr. Hay. CASES OF ORGANIC DUEAIEB OF THE BRAIN. 31* Synptomt. Case XXIII.—A man, aged 26—Se- vere headache; most distressing when ly- ing on the left side; occurring in parox- ysms with giddinesg. Afterseveral months pain increased, with impaired vision and dilated pupil. Paroxysms of giddiness, with blindness; loss of speech, stiffness of the limbs during the paroxysms; then dou- ble vision; violent pain in the neck, with convulsive paroxysms, affecting the mus- cles ofthe neck, and drawing the head vi- olently backwards. Two months after this he had numbness and spasmodic motions of the superior extremities. After seven or eight months died suddenly in a fit re- sembling epilepsy. Morbid Apppearances, A hard tumor two inches long, and an inch and a half broad, was firmly attached to the tentorium, and embedded in the pos- terior lobe ofthe left hemisphere It con- tained an ounce of greenish pus, and th« cerebral substance near it was softened. Where the tumor pressed against the oc- cipital bone, the dura mater was oblitera- ted, and the bone rough. Two ounces of fluid in the ventricles. Clercjc, Edin. Jour. VI. p 275, Case XXIV.—A man aged 35—'Severe headache, and sense of weight in the head for two years; copious epistaxis; loss of the sense of smell; then frequent epileptic par- oxysms for two years—died suddenly. Cerebral substance on the anterior p»rt of the right hemisphere was hard and callous, and adhered intimately to the dura mater; an the left side some evtravasated blood. Morgagni, Epis. 9. Case XXV.—A man, (age not men- tioned)—severe headache, followed by am- aurosis and epileptic paroxysms, which oc- curred almost daily. He died in an apo- plectic attack. On the inner surface of the left parietal bone, there was an osseous spongy tumor, three inches broad, and more than an inch in thickness. Wepfer. SECTION IV. Fourth Class—Convulsions, without affections of the senses.—Intellect sometimes impaired. Case XXVI—A man, aged 60—Epi- leptic for six years, with loss of memory. Died suddenly. An hydatid the size of a pigeon's egg, in the posterior part of the 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. Cas 3 XXVII.—A boy, aged 16 months, formerly heahhy, was seized with an attack of convulsiom It affected chiefly his right side, which was very strongly convulsed. He had a second attack on the evening of the same day, after which he had fever, blindness, and loss of the power of degluti- tion In this state he continued ten days, when he had another fit, and after this he gradually recovered his sight and degluti- tion From this time there was a degree of paralysis of the right side, but in other re- pecU he enjoyed good health for four years On the surface of the brain, under the left parietal bone, there was a tumor the size of an egg, situated between the pia ma- ter and the arachnoid; internally it was of a white and somewhat gelatinous appear- ance, but very firm, and when cut into, some serous fluid was discharged from it; no effusion. Comrnvriiicaled by Dr. Beilby. 316 supplement to part hi. Symptoms. He then had eliptic paroxysms, which at first occurred once in two months, but grad- ually increased in frequency. After a much longer interval than usual, a few weeks be- fore 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 right lower ex- tremity was three inches . shorter than the other;—his intellect had been weak, so that he never could be taught to read, Morbid Appearancet, 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 confined for several weeks After his recovery he be- came epileptic. The fits generally occur- red once in five or six weeks. After two years he fell from his seat behind the coach in one ofthe fits, and received various inju- ries, of which he died in a few days. There was thickening of the dura mater in several places. Attached to the inner surface of the thickened portions, therejwero several small nodules of bone, the size of peas, and very irregular on the surface. Communicated by Dr. Hunter. Case XXIX.—A child aged 20 months —No symptom remarked but a constant motitfn of the head from right to left—was pale but without fever, and did not seem to suffer. Died emaciated. In right lobe ofthe cerebellum a round firm cyst, the size of a hazel-nut, contain- ing numerous small hard concretions like pieces of bone. Andrei. Case XXX.—A woman aged 50— Epileptic for thirty years ; had cough which excited acute pain under the upper part ofthe occipital bone. In one ofthe epileptic fits she received a violent blow on this spot, followed by constant pain, and after six weeks, a pulsatory tumor appear- ed 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 aim, and both lower extremities, and soon after died. The tumor was generated in the sub- stance of the dura mater. It projected in- wards 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 ne.ir it was remarkably vascular. Mvrigues. Mem de Chir. p. 26. Case XXXI.—A woman of 43—Head- ache; spasmodic affections of the limbs. After seven months was confined to bed— violent paroxysms of headache, with loss of memory, and frequent convulsive attacks, which at last occurred several times a day. Died suddenly in one of them, six or seven weeks after she was confined to bed. Four ounces of fluid in the ventricles. A tubercle the size of a nut in the left lobe of the cerebellum; surrounding substance much softened. Rochoux tur VApop. It is unnecessary to detail particularly the cases of this class. They present the usual symptoms of the epileptic paroxysm, occurring at various intervals, and in various degrees of severity; sometimes ac- companied hy violent attacks of headaehe, and sometimes with little uneasiness in the head. They are sometimes fatal suddenly in one of CA9ES OF ORGANIC DISEASES OF THE BRAIN. 317 the fits, sometimes by coma. A variety of morbid appearances have been observed in such cases. Portal observed a remarkable indura- tion ofthe pons Varolii; and Sandifort found three tubercles in the dura mater near the sagittal suture, on the right side, and in the ante- rior part of the right hemisphere, a sebaceous tumor the size of a wal- nut. In a case by Lieutaud, there were seven sarcomatous tumors near the longitudinal sinus; and in another, a glandular tumor the size of a bean, in the substance ofthe 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. irregular piece of bone in the substance of the cerebellum, an inch long, and half an inch broad. In a case by Dr. Anderson 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 ofthe body. In a case of this kind by Dr. Anderson, a portion of the brain oil the opposite side was much indurated, with adhesion and thickening ofthe 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 bad violent headache for three months, then violent convulsions, which were rapidly fatal. The longitudinal sinus, externally and internally, was covered:, with innu- merable smaller 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 glandular 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. Morbid Appearances. Case XXXII.—A woman of 77—vio- A bard yellow cancerous mass, larger lent convulsions of the left arm, which re- than a duck's egg, and composed of many turned every two or three days for ten lobes in the substances of the right hemis- weeks, with weakness of the arm, then phere. weakness ofthe leg, and gradually com- Rostan, (Ramollissement de Cerveau) 318 SUPPLEMENT TO PART III. Symptoms. plete hemiplegia, the convulsion then ceas- ing—speech then lost, but mind entire— death after eleven months without any other symptom Case XXXIII —A boy, aged 11—sud- den attack of dimness of sight amounting to blindness. It went off in a few minutes, but from that time his sight was gradually impaired, and after a year was nearly lost. He then had an affection resembling chorea; and after a short time, suffered an attack in which he lay speechless for three days. This was followed by hemiplegia of the ri»ht side. He complained much of his head, which appeared to his friends to en- large; 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 continu- ance, about a year after the attack of hemi- plegia, and two years after the commence- ment ofthe disease. Case XXXIV —A man of 63—after a blow on the head, headache and sense of weight in the head, at first occurring in paroxysms, then more permanent, with slight weakness of the right side and tran- sient loss of recollection. Symptoms gra- dually increased to perfect hemiplegia of the right side—loss of speech—twisting of the mouth to the left, and great failure of intellect. Died comatose after more than two years. The coma continued a week. Morbid Appearances. On the surface of the left hemisphere, the membranes adhered firmly to tho sur- face 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 im- mense hydatid contained within the left late- ral ventricle, and which had nearly advanc- ed to the circumference of the brain. Itcon- tained about sixteen ounces of limpid fluid, and besides this, there were several ounces in the proper cavity of the ventricle. Communicated by Mr. Headington of London. A reddish-brown and firm tumor, 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 n line or more in diameter, and very firm. The tumor adhered slight- ly to the dura mater and the arachnoid, which was red and thickened where it covered the tumor. Below it was embed- ded in the substance of the hemisphere, and the cerebral matter was softened. One ounce of fluid in the ventricles Rochoux. Case XXXV. —A boy of 13—headache __hemiplegia of ihe left side for five or six weeks before deaih—loss of speech and memory—rigidity ofthe paralyzed limbs— occasional pain in the affected leg, and tremulous motions of both arms—tetanic symptoms. Case XXXVI.—A man, aged 36—oc- casional attacks of severe headache, shoot- ing from behind forwards. After a few months double vision—then gradually pal- sy of the right side, with distortion of the mouth and inarticulate speech; the left eye drawn towards the nose—pulse natu- ral. About two months from the com- mencement of the paralysis, he became convulsed, and died in twenty-four hours. A tubercle the size of a large egg, und five or six smaller ones in the substance of the right hemisphere; four in the left, the size of chesriuts—several of thetp suppurat- ed—pus betwixt the arachnoid and pia ma- ter, and turbid fluid in the ventricles. Bouillaud. A tumor, the size of a hazel-nut, lying on the left side of the tubor annulare, and sunk into it. .It extended to the left cor- pus pyramidale, compressing it and the ab- ductor nerve, and was closely attached to the basilar artery, which contained at this place a small coagulum, and its coals were very soft. The tumor was in a state of imperfect suppuration Yelloly, Med. Chir. Trans. J. 181. Case XXXVII.—A girl, aged 6 1-2—- Tuber annulare enlarged and lobulated, gradnal loss of power of right arm and leg, and changed into a gelatinous mass with cases of organic diseases of the brain. 319 Symptoms. Morbid Appearances. with great rigidity — squinting — loss of white bands running through it. Effusion nrticulation—difficult deglutition—palsy of in the ventricles. left side of face. Limbs of left side after- Bright- wards affected, though in a smaller degree than tho right—afterwards difficult respira- tion—complete loss of power of deglutition. Death in five months. The cases of this, class present little variety in the symptoms. They are generally, headache with or without affections 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 sim- ilar 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 paraly- tic, and soon after he died of convulsion. Two small encysted tu- mors 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 middle lobe. They were internally cellular, and contained blood mixed with a fila- mentous substance, and a matter resembling concrete pus. § II.—Paraplegia. Symptoms. Case XXXVI1L—A man of 48—acute headache for a year followed by paraple- gia. Five months after died suddenly. Case XXXIX.—A man of 35—fixed pain in the occiput extending down the neck—occasional vertigo and sickness. After five months hemiplegia of the left side and impaired vision. Hemiplegia di- minished gradually, and after five or six months more, became liable to fits of stu- por, which were preceded by violent pain and vertigo, and occurred occasionally twenty times in a day—blindness of the ri"ht eye—failure of memory—then para- plegia, and a fortnight before his death palsy of the upper extremities also.—Du- ration of the complaint was a year and eight months. Morbid Appearances. Left lobe of the cerebellum was almost entirely scirrhous, of a pale flesh-color, and seemed to be composed of numerous small corpuscles closely compacted, without any interstices, or any appearance of vessels. Morgagni, Ep. 62. On the surface ofthe pons Varolii, there were two triangular fleshy tumors nearly united by their apices. The base ofthe one extended into the right cms cerebri, that of the other into the medulla oblonga- ta. The disease penetrated into the sub- stance of the pons. There was much effu- sion under- the arachnoid. Edin. Jour. XL 470. 820 SUPPLEMENT TO PART III. Symptoms. Morbid Appearances. Case XL.—A man, aged 63—general A tumor the size of a hen's egg in the and complete paralysis of the whole body, medullary substance of the left hemisphere, which came on gradually and insensibly, betwixt the fissure of Sylvius and the part without any evident cause—speech indis- which rests upon the tentorium. It was linct—mind entire to the last. Died of contained in a cyst, and was internally of gangrene ofthe nates. a brownish color 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 exam- ination ofthe spinal cord; and perhaps it may still be considered as a point not absolutely ascertained, whether disease 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 frequent- ly exist both in the brain and in the cord at the same time, and that this particularly is true of tubercles. In a case related by Dr. Hawk- ins in the Medical and Physical Journal for 1826, there were nume- rous scrofulous tubercles, both in the brain and cerebellum in a man of 23; the symptoms had been fits resembling-epilepsy, with dysuria, partial paraplegia, and impaired speech and vision. He died after four months, having been comatose for three or four days before death. Had the spinal cord been examined in this case, it is very probable that tubercular disease would have been met with in it also. The same observation applies to a case by Bouillaud, in which there was paraplegia with loss of speech and intellect, in connexion with a tuber- cular mass, the size of a turkey's egg in the anterior part of the right hemisphere. A girl, aged 14, mentioned by Lallemand, had hemi- plegia of the right side, of which she recovered; four months after she had paraplegia with loss of feeling, which extended over the abdomen and the thorax; she died in sixteen days. There was remarkable in- duration of a small part ofthe left lobe ofthe brain, on the outside of the ventricle, and in the vettebral canal there was extensive extrava- sation of blood with ramollissement- 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 dyspepsia, with headache. In Morbid Appearances Four ounces of fluid in the ventricles. On the inferior part of the left lobe of the cerebellum, there was an encysted tumor, CASES OF ORGANIC DISEASES OF THE BRAIN. 321 Morbid Appearances. the size of a. French walnut, besid esa ves- icular portion connected with it, containing some yellow serum. The tumor was in- vested both by the dnra mater and pia ma- ter, and was attached by a small pedicle to the substance of the cerebellum, where it had formed a depression in which it was embedded. On the corresponding part of the opposite lobe there was a small florid tumor, the size of a large pea. The abdo- minal viscera were sound. Med. Repos. vol. vii. Symptoms. October, 1815, he had severe headache with fever, relieved by blood-letting; then complete want of digestion, headache, gen- eral emaciation, and frequent vomiting, which occurred chiefly in the morning. He had various uneasy feelings, which he re- ferred to his liver,"and his complaints were ascribed to this source by the most eminent practitioners whom he consulted. In Au- gust, 1816, he had severe headache, and nothing agreed with his stomach; almost every thing being vomited. After some time the pain was relieved, but the morn- ing sickness and vomiting continued, with increasing emaciation, torpid bowels, fre- quent eructations, and hiccup- In the end of September had twice a slight convulsion. Headache then periodical—mind entire, but conversation induced headache, and some- times convulsion. October 9, died sudden- ly in convulsion. Case XLII.—An officer, aged 27—con- The dura mater covering the cerebellum slant nausea and frequent vomiting—slight at its posterior and inferior part was thick- thickening of the pericranium—headache ened and cartilaginous, and the diseased and general indisposition. After a consid- state had extended considerably into the erable time, numbness of the right side, substance of the cerebellum, where it lay Five weeks after this, he died suddenly in in contact with it. Other parts of the cer- thenieht ebellum softened, membranes of the spinal B ' cord hard and thickened- Thoracic and abdominal viscera sound. Med. Repos. vol- viii. Many other cases are on record, in which the only morbid appear- ances were in the head, though some of the most prominent symptoms had been in the stomach. Some of these resemble what has been call- ed sick headache, while others are chiefly distinguished by remarkable disturbance of the digestive functions. There is generally more or less headache, 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, obtuse head- ache debility and emaciation; then vomiting, with more acute head- ache, and he died after various intermissions. Three tumors were found in the brain, one in the situation of the corpora quadngemina, and two others the size of walnuts in the substance ofthe brain. A vounc man, mentioned in the Medical Observations and inquiries, vol. vT had various complaints in the head and bowels, which were ascrib- ed to worms. After some time he had attacks of stupor and forget- fulness, and died delirious. The only morbid appearance was oss.fi- S^S^^^^^^^ -H* appearance in a 41 322 SUPPLEMENT TO PART III. gentleman who had been long affected with a train of obscure com- plaints, the most urgent of which were obtuse headache, with frequent vomiting. (Mem. Med. Soc. of London, vol. iii.) On the other hand, it is to be kept in mind that similar ossifications have been met with 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—head- ache, with occasional attacks of giddiness, and loss of recollection. He did not gen- erally fall down, but sometimes continued walking, without knowing whither he was going; at other times the attack resembled intoxication; his gait was feeble and totter- ing, and the attacks gradually increased in frequency and violence, though h^generally recovered his recollection in a very short time; but at length, after six months, a more severe attack occurred, from which he did not recover; he was now confined to bed with severe headache, giddiness, loss of memory, and incoherence; and about the 12th day had severe pain and partial palsy of the left leg and arm. He had then gen- eral convulsion, followed by perfect hemi- 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 readi- ly, had constant headache 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 fasted about an hour and a half, and he had warning of their approach so as to lay himself down. In the intervals all the functions were natural. After sev- en or eight months, the paroxysms became more frequent, and he died suddenly in one of them. Morbid Appearances. Three ounces of .fluid in the ventricles, cerebral substance very firm. In the pos- terior lobe of the right hemisphere, there was a firm tnmor the size of a smalt pig- eon's egg; internally of a pale flesh-color, 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 ventri- cle so as to form part of the wall ofthe pos- terior and inferior cornua, and the margin of the pes hippocampi was attached to it. The pia mater lining the ventriole at this place was very vascular. Communicated by Dr. Hunter. A scrofulous tumor, larger than a hen's egg, in the middle of the left hemisphere of the brain, extending 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 sizre of the finger-nail, was attached to the left side of the longitudinal sinas. Tho veins on the left hemisphere were more distended with blood than those on ihe right. Med. Chir. Trans. IV. 188. Case XLV.—A woman, aged 28—se- vere headache, constant vertigo, nausea, occasional vomiting, frequent rigors, pain and deafness of the left ear, and the left eye somewhat affected. After sever;; I months the headache increased, with oc- casional paroxysms of the coma, and she A remarkable tumor under the base of the brain on the left side, resting on the petrous portion of the temporal bone. It consisted of three portions; the anterior was the size of an egg, of a pink color, and composed of a spungy vascular substance, like the texture ofthe placenta, intewpers- CASES OF ORGANIC DISEASES OF THE BRAIN. 323 Symptoms. Morbid Appearances. died at last rather suddenly, having been ed with small cysts, containing a puriform for a day or two affected with extensive fluid; the posterior portion was half the erysipelas ofthe head and face- size ofthe former, and of similar structure, but firmer; the middle portion was the size of a walnut of a white color, and near- ly cartilaginous structure. The petrous portion of the bone on which the tumor rested was absorbed to the depth of half an inch. Case XLVI.—A lady, aged 64—at- Two small aneurisms, each about five- tacks of headache; giddiness and imperfect eighths of an inch in diameter, formed by vision occurring at uncertain intervals; af- dilation of the internal carotid arteries, by terwards mania; at last, after five years, the side of the cella Turcica, and contain- dcath with fever and delirium. ing lamina? of coagulated blood. Trans, of a Soc. II. 193. Case XLVII—A woman, aged 65— Extravasation of blood and ramollisse- palsy ofthe right leg of longstanding; Ian- ment. The anterior part of the left hem- cinating pains ofthe head, occurring at isphere was very much hardened, and of a intervals; attacks of insensibility; death reddish color. In the substance of the from gradual coma after an apoplectic at- right hemisphere there was an oval tumor taci<. of a reddish color, partly hard and partly softened. Rostan. 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 laminae of the dura mater,—(See Case VI. page 44.) and there are many others on record exhibiting some vari- eties of the symptoms. In some we find constant uneasiness, with vertigo; in others, transient apoplectic attacks, while the patient in the intervals enjoys tolerable health. In other cases again, there is a constant complaint of slight and habitual giddiness, commonly call- ed weakness of the head, often accompanied by unsteadiness 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 exam- ple 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 ofthe membranes, and a polypous tumor under the frontal bone. A gentleman, men- tioned by Gooch, had been for several years liable to attacks in which there was sometimes a shaking ofthe head, and a kind of emprostboto- nos; at other times he became vertiginous, and fell down, deprived of sense for a short time. He was never entirely free from head- ache, and brisk exercise excited giddiness, which went off immedi- ately'upon resting. He died suddenly in convulsion, and there were found several osseous points arising from the right parietal and occip- ital bones, and irritating the dura mater, which was inflamed, and be- ginning to' mortify.—(Gooch's Appendix, p. 237.) 324 SUPPLEMENT TO PART Ilf. To this class also belong the cases in which, connected with or- ganic disease of the brain, there has occurred a gradual loss of the mental faculties, with little complaint of pain, or any urgent symptom. In a case of this kind, which terminated in perfect stupidity or lethar- gy, 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. THE END- WOKKS ON MEDICINE, SURGERY, ANATOMY, MIDWIFEKY, AND THE COLLATERAL SCIENCES, PUBLISHED BY LEA & BLANCHARD, PHILADELPHIA, AND FOR SALE BY ALL BOOKSELLERS. MIDWIFERY ILLUSTRATED. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, IN REFERENCE TO THE PROCESS OF PARTURITION; ILLUSTRATED BY ONE HUNDRED AND FORTY-TWO FIGURES. BY FRANCIS H. RAMSBOTHAM, M.D., Physician to the Royal Maternity Charity, and Lecturer on Midwifery at the London Hospital, &c. 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The objects of this work are, 1st, to teach those who have the charge of children, either as parent or guardian, the most approved methods of securing and improving their physical powers. This is attempted by pointing out the duties which the parent or the guardian owes for this purpose, to this interesting but helpless class of beings, and the manner by which their duties shall be fulfilled. And 2d, to render avail- able a long experience to those objects of our affection when they become diseased. In attempting this the author has avoided as much as possible, " technicality;" and has given, if he does not flatter himself too much, to each disease of which he treats, its appropriate and designating characters, with a fidelity that will prevent any two being confounded together, with the best mode of treating them, that either his own experience or that of others has suggested. Physicians cannot too strongly recommend the use of this book in all families. A NEW WORK,—DUNGLISON'S THERAPEUTICS AND MATERIA MEDICA. GENERAL THERAPEUTICS AND MATERIA MEDICA, ADAPTED FOR A MEDICAL TEXT-BOOK, BY ROBLEY DUNGLISON, M.D., Professor of Institutes of Medicine, &c, in 2 vols. 8vo.—Just ready. A second edition of the work on General Therapeutics, being called for by the publishers the author has deemed it advisable to incorporate with it an account of the different articles ofthe Materia Medica To tins he has been led by the circumstance, that the departments of General Therapeutics and Materia Medica are always associated in the Medical Schools. The author's great object has been to prepare a work which may aid the Medical Student in acquiring the main results of modern observation and reflec- tion ; and, at the same time, be to the Medical Practitioner a trustworthy book of reference Throughout, he has adopted the Nomenclature of the last edition of the Pharmacopo3ia of the United States, a work which ought to be in the hands of every practitioner as a guide in the preparation of medicines; and he has endeavoured to arrange the articles in each division, as nearly as he could in the order of their efficacy as Therapeutical agents. . ' DEWEES' MIDWIFERY. A COMPENDIOUS SYSTEM OF MIDWIFERY, chiefly designed to facilitate the inquiries of those who may be pursuing this branch of study. Illustrated by occa- sional cases, with many plates. The tenth edition, with additions and improvement* by W. P. DEVVEES, M.D, late Professor of Midwifery in the University of Penn- sylvania, in one volume 8vo. LEA &. BLANCHARD'S PUBLICATIONS. A NEW WORK ON ANATOMY, WITH ONE HUNDRED AND SEVENTY ILLUSTRATIONS. A SYSTEM OF HUMAN ANATOMY, GENERAL AND SPECIAL, BY ERASMUS WILSON, M.D., Lecturer on Anatomy, London. The American edi- tion, edited by Paul B. Goddard, A.M., M.D., Demonstrator of Anatomy in the Uni- versity of Pennsylvania, &c.; with one hundred and seventy illustrations on wood, by Gilbert, from designs prepared expressly for this work, by Bagg, printed from the Becond London edition, in 1 vol. 8vo.—Just ready. "An elegant edition of one of the most useful and accurate Systems of Anatomical Science, which has been issued from the press. The illustrations are really beautiful, and their execution reflects the highest credit on the able American artist who copied them for this edition of the work. In its style the work is extremely concise and intelligible. Dr. Goddard has added a number of valuable notes, and has made some judicious alterations of names. No one can possibly take up this volume without being struck with the great beauty of its mechanical execution, and the clearness of the descriptions which it contains is equally evident. Let Students, by all means, examine the claims of this work on their notice, before they purchase a text-book of the vitally important science which this volume so fully and easily unfolds."—Lancet. HOPE ON THE HEART-WITH PLATES. A TREATISE ON THE DISEASES OF THE HEART AND GREAT VES- SELS, AND ON THE AFFECTIONS WHICH MAY BE MISTAKEN FOR THEM, COMPRISING THE AUTHOR'S VIEW OF THE PHYSIOLOGY OF THE HEART'S ACTION AND SOUNDS, AS DEMONSTRATED BY HIS EXPERIMENTS ON THE MOTIONS AND SOUNDS IN 1830, AND ON THE SOUNDS IN 1834-5, BY J. HOPE, M.D, F.R.S., of St. George's Hospital; formerly Senior Physician to the Marylebone Infirmary; Extraordinary Member, and formerly President, of the Royal Medical Society of Edinburgh, &c. First American from the Third London Edition, with Notes and a detail of recent Experiments, by C. W. Pennock, M.D., Attending Physician to the Philadelphia Hospital, Blockley. In 1 vol. 8vo. " The addition of one-third of new matter to the present volume, and the care with which the whole has been revised and corrected, will, I trust, sufficiently prove my respect fqr the favourable opinion of my professional brethren, as evinced, not in this country only, but also on the European and American continents, by the sale of no less than six or seven editions and translations in as many years."—Ex- tract from Preface. MEDICAL REMEDIES. NEW REMEDIES. THE METHOD OF PREPARING AND ADMINIS- TERING THEM; THEIR EFFECTS UPON THE HEALTH AND DISEASED ECONOMY, &c. &c, BY PROFESSOR ROBLEY DUNGLISON. Fourth edi- tion, brought up to 1843. In one volume octavo. This work contains articles that have been recently introduced into the Materia Medica; or old articles^ that have received new applications, some of these are in the general works on Materia Medica, but their properties are only briefly referred to. In this work, the experience of individuals is extensively given, with reference to the original papers. Under Iodine, for example, all the information—pharma- ceutical and therapeutical—up to the time of the publication of the work, is afforded, with the prescrip- tions that have been proposed by various observers; each successive edition has incorporated with it the result of recent experience, and is therefore " new." MIDWIFERY WITH CUTS, A LATE WORK. A SYSTEM OF MIDWIFERY, WITH NUMEROUS WOOD CUTS, BY EDWARD RIGBY, M.D., Physician to the General Lying-in Hospital, Lecturer on Midwifery at St. Bartholomew's Hospital, &c, with notes and additional Illustrations, by an American Practitioner. In one volume. The late Professor Dewees, into whose hands this volume was placed a few weeks before his death, in returning it, expressed the most favourable opinion of its merits. The judgment of such high authority should commend it to general favour. DISEASES OF FEMALES. A TREATISE ON THE DISEASES OF FEMALES, WITH NUMEROUS ENGRAVINGS, BY THE LATE PROFESSOR W. P. DEWEES, in one volume gvo__the Eighth Edition, revised and corrected. LEA & BLANCHARD'S PUBLICATIONS. DISEASES OF FEMALES, PREGNANCY AND CHILDBED. THE PRINCIPAL DISEASES OF FEMALES, TOGETHER WITH THE DISEASES INCIDENT TO PREGNANCY AND CHILDBED, CHIEFLY FOR THE USE OF STUDENTS, BY FLEETWOOD CHURCHILL, M.D., Lecturer on Midwifery and Diseases'of Women and Children, in the Richmond Hospital, School of Medicine, &c. &c, with Notes and Additions by R. M. Huston, M.D., Professor, &c. in the Jefferson Medical College. Second American Edition, in 1 vol. 8vo.—Just ready, DUNGLISON'S PHYSIOLOGY-WITH ILLUSTRATIONS. HUMAN PHYSIOLOGY, ILLUSTRATED WITH OVER TWO HUNDRED ENGRAVINGS ON WOOD; BY PROFESSOR ROBLEY DUNGLISON; the fourth edition with numerous additions and modifications, in 2 vols. 8vo. This work is occupied with the functions executed by healthy man. It embraces a general exposition of the functions; the new views entertained in regard to the formation of the tissues ; hut is especially intended to give an accurate view of the actions of the different organs, as an introduction to the study of pathology, hygiene and therapeutics. It treats moreover, of the anatomy of the organs so far as is necessary for a full understanding of the functions ; and is largely illustrated by appropriate engravings. The last edition contains several additional illustrations to elucidate either topics that have been already touched upon in the work, or such as are new. Every effort has been made to place the work, in all respects, on a level with the existing state ofthe science. THE DISEASES OF THE EYE. A TREATISE ON THE DISEASES OF THE EYE, BY W. LAWRENCE, Surgeon Extraordinary to the Queen, &c, from the last London Edition, with numerous additions, and sixty-seven Illustrations, many of which are from original drawings. By Isaac Hays, M.D., Surgeon to the Wills Hospital, &c, &c, in 1 vol. 8vo.— Just ready. The character of this work is too well established to require a word of commendation—it is justly considered the best on the subject. The present is a reprint of the last London Edition, which appeared in 1841, completely revised and greatly enlarged by the author—and to it considerable additions have been made by the editor. Several subjects omitted in the original are treated of in this edition, on which occasion free use has been made of the work of Mackenzie, to which is added the editor's own experi- ence, derived from many years' attention to the subject. THE URINARY ORGANS, &c. LECTURES ON THE DISEASES OF THE URINARY ORGANS, BY SIR B. C. BRODIE, BART. F.R.S. From the Third London Edition, with alterations and additions, a small 8vo. volume.—Now ready. The work has throughout been entirely revised, some of the author's views have been modified, and a considerable proportion of new matter has been added, among which is a Lecture on the Operation of Lithotomy. RICORD ON VENEREAL. A PRACTICAL TREATISE ON VENEREAL DISEASES; OR, CRITICAL AND EXPERIMENTAL RESEARCHES ON INOCULATION, APPLIED TO THE STUDY OF THESE AFFECTIONS; WITH A THERAPEUTICAL SUMMARY AND SPECIAL FORMULARY, BY PH. RICORD, M.D. Surgeon of the Venereal Hospital of Paris, Clinical Professor of Special Pathology, °&c. Translated from the French, by Henry Pilkington Drummond, M.D., in one volume. —Now ready. LAWRENCE ON RUPTURES. A TREATISE ON RUPTURES, BY W. LAWRENCE, F.R.S., Author of a Treatise on the Diseases of the Eye, &c. &c, from the Fifth London Edition, consi- derably enlarged. In 1 vol. 8vo.—Now ready The peculiar advantage of the treatise of Mr. Lawrence is, that he explains his views on the anatomy of hernia, and Uipdifferent varieties ofthe disease, in a manner which renders his book peculiarly useful to the student. It must be superfluous to express our opinion of its value to the surgical practitioner. As a treatise on hernia, presenting a complete view of the literature of the subject, it stands in the first rank.—Edinburgh Medical and Sunjical Journal. LEA & BLANCHARD'S PUBLICATIONS MEDICAL LEXICON, BROUGHT UP TO 1842. A NEW DICTIONARY OF MEDICAL SCIENCE; Containing a concise account of the various Subjects and Terms, with the French and other Synonymes, and Formulre for various Officinal and Empirical Preparations, &c. Third Edition, brought up to 1842. BY ROBLEY DUNGLISON, M.D, Professor in the Jefferson Medical College, &.c. In One Volume, royal 8vo. " The present undertaking was suggested by the frequent complaints, made by the author's pupils, that they were unable to meet with information on numerous topics of Professional Inquiry,—especially of recent introduction,—in the medical dictionaries accessible to them. " It may, indeed, be correctly affirmed, that we have no dictionary of medical subjects and terms which can be looked upon as adapted to the state of the science. In proof of this the author need but to remark, that he has found occasion to add several thousand Medical Terms, which are not to be met with in the only medical lexicon at this time in circulation in this country. " The present edition will be found to contain many hundred Terms more than the first, and to have experienced numerous Additions and Modifications. " The author's object has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensed view of its various medical relations, and thus to render the work an epitome ofthe existing condition of Medical Science." This New Edition includes, in the body of the work, the Index or Vocabulary of Synonymes that was in the former Editions printed at the end ofthe Volume, and embraces many Corrections, with the addi- tion of many New Words. PEREIRA'S MATERIA MEDICA, EDITED BY DR. CARSON, WITH NEAR THREE HUNDRED ENGRAVINGS ON WOOD. ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS; COMPRE- HENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPOSITION, EFFECTS, AND USES OF MEDICINES, BY JONATHAN PEREIRA, M.D, F.R.S., Assistant Physician to the London Hospital, &c. Part I, contains the General Action and Classification of Medicines, and the Mineral Materia Medica. Part II, the Vegetable and Animal Kingdoms, and including diagrams explanatory of the Processes of the Pharmacopoeias, a Tabular view of the History of the Materia Medica, from the earliest times to the present day, and a very copious index. From the Second London Edition, which has been thoroughly revised, with the Introduction of the Processes of the New Edinburgh Pharmacopoeia, and containing additional articles on Mental Remedies, Light, Heat, Cold, Electricity, Magnetism, Exercise, Dietetics, and Climate, and many additional Wood Cuts, illustrative of Pharmaceutical Operations, Crystallogra- phy, Shape and Organization ofthe Feculas of Commerce, and the Natural History of the Materia Medica, The object of the author has been to supply the Medical Student with a Class Book on Materia Medica, containing a faithful outline of this Department of Medicine, which should embrace a concise account of the most important modern discoveries in itfatural History, Chemistry, Physiology, and Therapeutics in so far as they pertain to Pharmacology, and treat the subjects in the order of their natural historical relations. This great Library or Cyclopedia of Materia Medica has been fully revised, the errors corrected, and numerous additions made, by DR. JOSEPH CARSON, Professor of Materia Medica and Pharmacy in the "College of Pharmacy," and forms Two Volumes, octavo, of near 1600 large and closely-printed pages; and it may be fully relied upon as a permanent and standard work for the country,—embodying, as it does, full references to the U. S. Pharmacopea and an account of the Medicinal Plants indige- nous to the United States. PRINCIPLES AND PRACTICE OF SURGERY, WITH CUTS. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY, BY RO- BERT DRUITT. From the Second London Edition, illustrated with fifty wood en- gravings, with notes and comments by Joshua B. Flint, M.D, in one volume 8vo., at a low price. EXTRACT FROM THE AUTHOR'S PREFACE. " The arrangement of a work of this kind ought not, as I conceive, to be regarded as a matter of mere indifference, or at most of convenience, but it ought to embody in it something of a principle; and I believe that the arrangement of this work may be useful to the student, by showing him in what order he niav best prosecute his researches into the principles of his profession. "Of the five parts into which it is divided, the first two are more especially devoted to the principles, and the three o hers to the practice of surgery. The first part treats of the disturbances of the constitu- tion at large, that may be produced by injury or disease of a part; beginn.ng with he simple faintness or collapse that follows a blow, and proceeding to consider the varieties of fever and tetanus. "The second part describes what maybe called the elements of local disease; that is to say, those morbid changes of structure or function, which are produced either immediately by external causes, or snrondarilv, tbrouch some deviation from health, &x. .......,_.,. u ■ ■ - ■ "The third part treats of the various kinds of injuries, beginning with the simplest mechanical inju- ries ; then proceeding to the effects of chemical agents, and lastly, considering the effects of animal P°"SThe fourth part considers the various tissues, organs, and regions of the body in order, and describes • »,» various acciilrnts they are liable to, &c. .,.,.., .. -Thp fifth part describes such of the operations as were not included in the former parts, Sec. ■• To the whole is appended a collection of formula;, the number of which is very much increased in this edition." LEA & BLANCHARD'S PUBLICATIONS. FEVERS OF THE UNITED STATES. THE HISTORY, DIAGNOSIS AND TREATMENT OF TYPHOID AND TYPHUS FEVER, WITH AN ESSAY ON THE DIAGNOSIS OF BILIOUS REMITTENT AND OF YELLOW FEVER, BY ELISHA BARTLETT, M.D., Professor of the Theory and Practice of Medicine in the Transylvania University. In one volume 8vo; a new work. Notice has already been given of the appearance of this work : we have become satisfied of its sterling value, and, therefore, without hesitation, feel justified in again recommending it to the immediate no- tice of practitioners.—Boston Medical and Surgical Journal. MULLER'S PHYSIOLOGY. ELEMENTS OF PHYSIOLOGY; BY J. MULLER, M.D, Professor of Ana- tomy and Physiology in the University of Berlin, &c. Translated from the German by William Baly, M.D., Graduate in Medicine of the University of Berlin. Ar- ranged from the Second London Edition by John Bell, M.D., Lecturer on Materia Medica and Therapeutics, &c, &c. In One Volume, 8vo.—Just ready. In arranging the Volume now offered to American readers, from the materials furnished in Muller's Elements of Physiology, the Editor has endeavoured to procure reduction in sizr, of this latter, with- out any abstraction of its vitality and mind. With this view he has omitted, for the most part, mere disquisitions, many details of experiments, matters of physics and natural philosophy, including mechan- ics under the head of locomotion, acoustics and the theories of music under voice and hearing, and of optics under vision,—much ofthe minulia; of comparative physiology, and metaphysics or inetaphysico- physiology. But, while excluding details on collateral topics, the Editor has been particularly careful to preserve Physiology Proper, which, resting on the basis of Histogeny and General Anatomy, derives important aid from Organic Chemistry and Microscopical Observations, and in its turn serves to illus- trate Hygiene, Pathology and Therapeutics. Thus aided and thus applied, in the manner exhibited by Miiller himself, Physiology will invite the attention ofthe Student in these pages. It will soon be discovered that, although this volume is an abridgement of the large work of Miiller, it may rightfully claim to be considered a complete system of Physiology, exceeding in copiousness and comprehensive details, any other work on the same subject which has yet emanated from the London press. ELEMENTS OF PHYSICS-WITH WOOD-CUTS. ELEMENTS OF PHYSICS, OR NATURAL PHILOSOPHY, GENERAL AND MEDICAL. A New Edition, complete in One Volume, written for universal use, in plain and non-technical language, and containing New Disquisitions and Prac- tical Suggestions; comprised in Five Parts: 1. Somatology, Statics and Dynamics. 2. Mechanics. 3. Pneumatics, Hydraulics and Acoustics. 4. Heat and Light. 5. Animal and Medical Physics. By NEIL ARNOTT, M.D., of the Royal College of Physicians. A New Edition, revised and corrected from the last English Edition ; with additions by Isaac Hays, M.D., and numerous Wood-cuts. PRACTICAL MINERALOGY AND GEOLOGY-WITH CUTS. A TEXT-BOOK OF GEOLOGY AND MINERALOGY, WITH INSTRUC- TIONS FOR THE QUALITATIVE ANALYSIS OF MINERALS. BY JOSHUA TRIMMER, F.G.S., with Two Hundred and Twelve Wood-cuts. A handsome Octavo Volume, bound in embossed cloth. This is a Systematic Introduction to Mineralogy and Geology, admirably calculated to instruct the Student in those sciences. The Organic Remains of the various Formations are well illustrated by numerous Figures, which are drawn with great accuracy. ELLIS'S MEDICAL FORMULARY IMPROVED. THE MEDICAL FORMULARY OF DR. ELLIS; being a COLLECTION OF PRESCRIPTIONS, derived from the Writings and Practice of many ofthe most eminent Physicians in America and Europe. To which is added an Appendix, con- taining the usual Dietetic Preparations and Antidotes for Poisons ; the whole accom- panied with a few brief Pharmaceutic and Medical Observations. By BENJAMIN ELLIS, M.D. The Seventh Edition, completely revised, with many Additions and Modifications, and brought up to the present improved state of the Science; by Samuel George Morton, M.D., Professor in the Pennsylvania College of Medicine, &c, &c. In One Octavo Volume. LEA & BLANCHARD'S PUBLICATIONS, PRINCIPLES OF MEDICINE. THE FIRST PRINCIPLES OF MEDICINE, BY ARCHIBALD BILLING, M.D., A.M., Member of the Senate ofthe University of London, Fellow ofthe Royal College of Physicians, iLc, &c. In One Volume, 8vo. First American from the Fourth London Edition. " \\V know of no book which contains within the same space so much valuable information, the result not of fanciful theory, nor of idle hypothesis, but of clo=e, persevering Clinical Observation, accompanied with much soundness of judgment, and extraordinary clinical tact."—Medico- Chirurgical Review. A TREATISE ON FEVER. By South wood Smith, M.D., Physician to the Lon- don Fever Hospital, fourth American edition. In one volume octavo. COATES'S POPULAR MEDICINE, OR FAMILY ADVISER, consisting of Outlines of Anatomy, Physiology, and Hygiene, with such Hints on the Practice of Physic, Surgery, and the Diseases of Women and Children, as may prove useful in families when regular Physicians cannot be procured: being a Companion and Guide for intelligent Principals of Manufactories, Plantations, and Boarding Schools; Heads of Families, Masters of Vessels, Missionaries, or Travellers; and a useful Sketch for Young men about commencing the Study of Medicine. By Reynell Coates, M.D. This work is designed to supply the place of Ewells' Medical Companion, which is now entirely out of print. OUTLINES OF A COURSE OF LECTURES ON MEDICAL JURISPRU- DENCE. By Thomas Stewart Traill, M.D., with notes and additions. A small volume. A PRACTICAL TREATISE ON MEDICAL JURISPRUDENCE, with so much of Anatomy, Physiology, Pathology, and the Practice of Medicine and Surgery, as are Essential to be known by Members of the Bar and Private Gentlemen; and all the Laws relating to Medical Practitioners; with Explanatory Plates. By J. Chitty, Esq., second American edition, with notes and additions adapted to American Works and Judicial Decisions. In One Volume Octavo. ABERCROMBIE ON THE BRAIN. Pathological and practical Researches on Diseases of the Brain and Spinal Cord. New edition, 1 vol. 8vo. A PRACTICAL TREATISE ON THE HUMAN TEETH, showing the causes of their destruction and the means of their preservation, by William Robertson. With plates. First American from the second London Edition. In one volume octavo. ANATOMY, PHYSIOLOGY, AND DISEASES OF THE TEETH. By Thomas Bell, F.R.S., F.L.S., &c. Third American edition. In one volume octavo, with numerous plates. DISSERTATIONS ON NERVOUS DISEASES. By Drs. James Hope, J. C. Prichard, John Hughes Bennett, Robert H. Taylor and Theophilus Thomson. In one volume octavo. DISSERTATIONS ON DISEASES OF THE ORGANS OF RESPIRATION. By Drs. Williams, Theophilus Thomson, W. B. Carpenter, and W. Bruce Joy. In one volume octavo. DISSERTATIONS ON FEVERS, GENERAL PATHOLOGY, INFLAMMA- TION, AND DISEASES OF THE SKIN. By Drs. Symonds, Allison, Christison, &c. &.c. In one volume octavo. DISSERTATIONS ON DISEASES OF THE DIGESTIVE, URINARY AND UTERINE ORGANS. By Drs. Joy, Symonds, Thomson, Ferguson, &c. &c. In one volume octavo. DISSERTATIONS ON HAEMORRHAGES, DROPSY, RHEUMATISM, GOUT, SCROFULA, &c. &c. By Drs. Burrows, Watson, Shapter, Joy, &c. &c. In one volume octavo. The above five volumes are from the Library of Practical Medicine, edited by Dr. Tweedie, with notes by Dr. Gerhard. Each volume is complete within itself, and is for sale separately. THE MEDICAL STUDENT; OR AIDS TO THE STUDY OF MEDICINE. Including a Glossary of the Terms of the Science, and of the Mode of Prescribing; Bibliographical Notices of Medical Works; the Regulations of the different Medical Colleges of the Union, &c. By Robley Dunglison, M.D., &c. &c. In one vol. Svo. _______LEA & BLANCHARD'S PUBLICATIONS. _ ESSAYS ON ASTHMA, APHTHA, ASPHYXIA, APOPLEXY, ARSENIC, ATROPA, AIR, ABORTION, ANGINA PECTORIS, and other subjects, embraced in the Articles from A to Azote, prepared for the Cyclopeedia of Practical Medicine by Dr. Chapman and others. Each article is complete within itself, and embraces the practical experience of its author, and as they are only to be had in this collection, will be found of great value to the profession. The two volumes are now offered at a price so low, as to place them within the reach of every practitioner and student. OUTLINES OF PHYSIOLOGY; with an Appendix on Phrenology. By P. M. Roget, M.D., Professor of Physiology in the Royal Institute of Great Britain, &c. First American edition revised, with numerous Notes. In one volume octavo. GEOLOGY AND MINERALOGY, considered with reference to Natural Theology. By the Rev. William Buckland, D.D., Canon of Christ Church, and Reader in Geo- logy and Mineralogy in the University of Oxford. With nearly one hundred copper- plates and large coloured maps. A new edition from the late London edition, with supplementary notes and additional plates. THE BRIDGEWATER TREATISES, complete in seven volumes octavo, em- bracing: I. The Adaptation of External Nature to the Moral and Intellectual Constitution of Man. By the Rev. Thomas Chalmers. II. The Adaptation of External Nature to the Physical Condition of Man. By John Kidd, M.D.F.R.S. III. Astronomy and General Physics, considered with reference to Natural Theology. By the Rev. William Whewell. IV. The Hand; its Mechanism and vital Endowments as evincing Design. By Sir Charles Bell, K.H., F.R.S. With numerous wood-cuts. V. Chemistry, Meteorology, and the Function of Digestion. By William Prout, M.D.F.R.S. VI. The History, Habits, and Instincts of Animals. By the Rev. William Kirby, M.A.F.R.S. Illus- trated by numerous engravings on copper. VII. Animal and Vegetable Physiology, considered with reference to Natural Theology. By Peter Mark Roget, M.D. Illustrated with nearly five hundred wood-cuts. VIII. Geology and Mineralogy, considered with reference to Natural Theology. By the Rev. William Buckland, D.D. With numerous engravings on copper, and a large coloured map. The works of Buckland, Kirby and Roget, may be had separate. A POPULAR TREATISE ON VEGETABLE PHYSIOLOGY, by W. P. Car- penter, Author of Principles of Human Physiology, &c, published under the auspices of the Society for the Promotion of Popular Instruction. With numerous wood-cuts, in one volume 12mo. A POPULAR TREATISE ON AGRICULTURAL CHEMISTRY; intended for the use of the practical farmer, by Charles Squarry, Chemist. In one vol. 12mo. ROGET'S ANIMAL AND VEGETABLE PHYSIOLOGY, with nearly five hundred wood-cuts, in two volumes, second American edition. THE HISTORY, HABITS, AND INSTINCTS OF ANIMALS, by the Rev. William Kirby, M.A.F.R.S. Illustrated by numerous copperplate engravings. The Ninth Bridgewater Treatise. A FRAGMENT, by Charles Babbage, Esq. From the second London edition. In one volume octavo. A PRACTICE OF PHYSIC. Comprising most of the diseases not treated of in Diseases of Females and Diseases of Children, second edition. By W. P. Dewees, M.D., formerly Adjunct Professor in the University of Pennsylvania. In one vol. 8vo. ELEMENTS OF HYGIENE; on the Influence of Atmosphere and Locality; Change of Air and Climate, Seasons, Food, Clothing, Bathing, Sleep, Corporeal and Intellectual Pursuits, &c, on Human Health, constituting Elements of Hygiene. By Robley Dunglison, M.D. In one volume 8vo. ABERCROMBIE ON THE STOMACH. Pathological and Practical Researches on Diseases of the Stomach, the Intestinal Canal, the Liver, and other Viscera of the Abdomen. By John Abercrombie, M.D. Third American, from the second London edition, enlarged. In one volume 8vo. DISEASES oFTHE SKIN. A NEW WORK. A PRACTICAL AND THEORETICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE SKIN, arranged according to a Natural System of Classification, and preceded by an Outline of the Anatomy and Physiology of the Skin. By Erasmus Wilson, M. D, author of a System of Human Anatomy, &c, in 1 vol. 8vo. ■{y; ;'.r.:;*j ^.; !& ./,£. •W-' *$*?, **■¥■■" Sfc *(&*";■ "..i^ fcivtr' 0 '/ i-Tit m W-n^*.r - 4^' 5 '.',-^K-.^ '->:.>■. ^■V^v «^J- #* 3* % tv '■/&:.&-£ :F« fHf *:• SM