MEDICAL CLINIC; REPORTS OF MEDICAL CASES i BY G. ANDRAL, \|* PROFESSOR OF THE FACULTY OT MEDICINE OF PARIS, MEMBER OF THE ROYAL Ji ACADEMY OF MEDICINE, ETC., ETC. (Eotrtiensett antr &ranslateo, | WITH OBSERVATIONS EXTRACTED FROM THE WRITINGS OF THE "\i MOST DISTINGUISHED MEDICAL AUTHORS: OF THE ASSOCIATION OF THE FELLOWS AND LICENTIATES OF THE COLLEGE OF PHYSICIANS, AND FORMERLY PHYSICIAN TO THE DUBLIN GENERAL DISPENSARY. .V\ D. SPILLAN, M.D. ^ FELLOW OF THE KING AND dUEEN's COLLEGE OF PHYSICIANS IN IRELAND, MEMBER ----------- 1 1 CONTAINING DISEASES OF THE ENCEPHALON, S^ S WITH EXTRACTS FROM ^S OLLIVIER'S WORK ON DISEASES OF THE SPINAL CORD AND ITS rj J MEMBANES. *f PHILADELPHIA: HASWELL, BARRINGTON, AND HASWELL, 293 MARKET STREET. 1838. . ... r \4\ ,) A S PREFACE. p.5 [ by the editor. ] An implied promise to the readers of the " Select Medical Library" will be fulfilled in the following pages, by the publication of that important portion of An- dral's Medical Clinic in which the Diseases of the Ence- phalon and its Membranes are described. The volume now given is essentially a distinct work, having no con- nexion with the other works under the head of Andral's Medical Clinic, other than identity of authorship. We shall probably introduce into the "Library," in the course of the ensuing year, the two volumes by the same author, on Diseases of the Abdominal Viscera and their Mem- branes. Two others, in which the Diseases of the Tho- racic Viscera are treated, will, for a time at least, be replaced by the valuable Lectures of Dr. Williams on the Physiology and Diseases of the Chest. The greater number of these are printed, and we only wait for the concluding ones from London, in order to place them entire before our readers. In this first American edition of the clinical experience of Andral on the Diseases of the Brain and its Meninges, we have made no change in the arrangement and narra- tive presented to us by the English translator, Dr. Spil- lan. We have, however, substituted, in many places, more idiomatic terms and phraseology for the gallicisms 4 PREFACE. and French terms in which the English edition abounds. Some of them have probably escaped our notice; but they will not, it is believed, detract from the intrinsic and indisputable value of the work, which may safely be pronounced to be of the very first order of merit. The accusation of difTuseness brought, not without reason, against some French works, cannot apply to the produc- tions of Andral's pen. In the present instance, there is no toying with the reader's attention,—no attempt to amuse him by analogies or speculations; but there is, on the other hand, a continuous description and detail of a class of morbid alterations of structure and of symptoms growing out of them, a knowledge of which, by American physicians generally, is not, we fear, as accurate as could be desired in the actual state of modern pathology. The suggestions thrown out by Andral are couched in a spirit of philosophic caution, which are in singular contrast with the hasty and premature induction so observable in medical writings on both sides of the Atlantic. We have retained all the notes, and the additions on the spinal mar- row and its membranes, introduced by the industrious and able translator, Dr. Spillan. The therapeutical details, given for the most part paren- thetically, are still in adequate number and distinctness to enable the American reader to obtain a tolerably clear idea of French hospital practice; and although they may not serve as a model for guidance, they will unquestionably furnish useful hints to strengthen our hands in the re- moval of disease. Philadelphia, August 22, 1838. CONTENTS. FIRST BOOK. DISEASES OF THE ENCEPHALIC MEMBRANES. i PAGE Section I.—Diseases of the Dura Mater,.....9 Section II.—Diseases of the Arachnoid and Pia Mater, . . 12 Chap. I.—Cases of Diseases of the Arachnoid and Pia Mater covering the upper surface of the Brain, 13 Chap. II.—Diseases of the Meninges of the lower surface of the Brain,......29 Chap. III.—Diseases of the Meninges covering the parietes of the Ventricles of the Brain, . . .31 Chap. IV.—Cases wherein the entire of the Meninges were involved,.......41 ' Chap. V.—Diseases of the Membranes of the Spinal Cord, 48 Recapitulation.—Chap. I.—Lesions detected in the Meninges by post mortem examination. Art. 1.—Lesions of the Dura Mater, . . . .60 Art. 2.—Lesions of the Arachnoid, .... 61 Art. 3.—Lesions of the Pia Mater.....63 Chap. II.—Disturbances of Function, .... 67 Art. 1.—Disturbances in the Functions of Relation, . 68 Oct. 1838.—0 2 CONTENTS TO ANDRAL'S CLINIC. SECOND BOOK. DISEASES OF THE BRAIN. PAGE 68 Section I.—Lesions of Sensibility, . Art. 2.—Lesions of Motion, . . . • • ^5 Art. 3.—Lesions of the Intellect, . . • • .82 Chap. III.—Disturbances of the Functions of the Organs of Nutritive Life,.....86 Art. 1.—Lesions of the Functions of the Digestive Ap- paratus, ....••• 87 Art. 2.—Lesions of the Circulation, .... 89 Art. 3.—Lesions of Respiration, . . • • .91 Supplement.—Spinal Meningitis, . . . • • .92 Symptoms of Meningitis, 95 First Order.—Cerebral Congestions, ..... 98 Recapitulation,.........106 Second Order.—Cerebral Hemorrhage, . . . . .133 Recapitulation.—Chap. I. Lesions of Motion, . . . .151 Chap. II. Lesions of Sensibility, . . .159 Chap. III. Lesions of the Intellect, . . 164 Chap. IV. Lesions of the Functions of the Or- gans of Nutritive Life, Supplement.—Spinal Congestions, ..... Third Order.—Softening of the Cerebral Hemispheres, Chap. I.—Cases where no Symptom announced the soft ening, ...... Chap. II.—Cases where the Disturbance of Motion was the only symptom, .... 167 169 189 191 192 CONTENTS TO ANDRAL'S CLINIC. 7 PAGE Chap. III.—Cases where, with different Lesions of Motion, there existed a Lesion of Sensibility, . . 205 Chap. IV.—Cases in which the Loss of Speech was the only Symptom, or one of the predominant Symptoms,......210 Chap. V.—Cases in which, with divers Disturbances of Motion and Sensation, there was Disorder of the Intellect,.....211 Art. 1.—Softening of the Brain, with complete and sudden Loss of Consciousness, . . 212 Art. 2.—Softening of the Brain, with Weakness or Perversion of the Intellect, . . .218 Recapitulation,.........224 Fourth Order.—Hypertrophy of the Cerebral Hemispheres, . 244 Fifth Order.—Observations on Atrophy of the Cerebral Hemi- spheres, .......253 Sixth Order.—Observations on Cancer of the Brain, . . 259 THIRD BOOK. DISEASES OF THE CEREBELLUM. Section I.—Observations on Hemorrhage of the Cerebellum, . 270 Section II.—Observations on softening of the Cerebellum, . 271 DISEASES ENCEPHALON AND ITS MEMBRANES. FIRST BOOK. DISEASES OF THE ENCEPHALIC MEMBRANES. SECTION I. DISEASES OF THE DURA MATER. Case I.—Fibrous vegetation on the inner surface of the dura mater, with considerable depression of the part of the brain corresponding to it—Hemiplegia—Intellect perfect —Headache of an old standing. A Military man, sixty-one years old, entered the Hospital La Charitt in the beginning of March, 1S29. He appeared to have been of a good constitution, but when he presented himself he was very much emaciated ; his countenance was of a pale colour, some- what yellowish ; one half of the right eyelid was depressed before the globe of the eye, and it was incapable of being completely raised at the will of the patient; both extremities of the right side were deprived of the power of motion, and their sensibility was impaired ; the urine was passed involuntary ; pulse remarkably slow. The patient stated that, after having experienced, for a long time, rheumatic pains in different parts of the body, he was seized, about the beginning of the year 1817, with a headache, seated principally towards the anterior part of the left parietal bone. This pain was at first intermittent; then became continued for an entire year; then, from the middle of 1819, it disappeared altogether, lhis headache, the only thing the patient complained of, was at times in- supportable. Nearly about the time it ceased, he thought the right upper extremity felt somewhat more insensible than the left, as did also the fingers of this side from time to time ; they were cold, and usually presented a violet appearance. He gradually became unable Sept. 1838.—/ 3 10 ANDRAL'S MEDICAL CLINIC. to grasp anything with the right hand. Subsequently, the right upper extremity became completely paralytic, at the same time that the left lower extremity lost the faculties of sensation and motion. For the first ten or twelve days after entering the hospital the state of the patient did not change ; then the tongue became dry, and the pulse frequent ; his intellects became disturbed ; diarrhoea came on ; a broad eschar formed on the sacrum, and the patient died in an adynamic state towards the end of March. . Post mortem.—Considerable emaciation. On raising the vault of the cranium, no appreciable lesion on the external surface of the dura mater. On making an incision, however, into it, this mem- brane was found to have contracted unusual adhesions to the subjacent parts. These adhesions were formed by cellular bands, which united the two layers of the arachnoid to each other. These bands circumscribed a spherical body of the size of a large nut, which sank deep into the cerebral substance, with which it had not contracted adhesion in any other part. It was separated from it by a cellulo- vascular layer, which appeared to be the tissue of the arachnoid and pia mater compressed by it. This body was attached by a narrow pedicle to the inner surface of the dura mater, the fibres of the latter membrane being dispersed over the pedicle of the tumour, and so confounded with its tissue, that to distinguish them was impossible. This tissue, which was of considerable hardness, and of a white ten- dinous appearance, consisted of fibres which were, as it were, wound up one upon another ; they seemed a prolongation of the fibres of the dura mater. Some infarction in the posterior part of the lungs ; two white spots on the pericardium, The mucous membrane of the stomach, towards the great cul de sac, presented some red points ; the end of the ileum and part of the colon, presented a bright red colour. Remarks.—From the nature of the symptoms and progress of the disease, one would have expected that softening was the lesion to be found in the brain in this case. That permanent flexion of the limbs oftentimes, though not always, accompanying softening, was not however here observed at any period. The rheumatic pains preceding the pain of head, might have led one to consider the latter also as rheumatic. There is not a doubt but that pain of head simi- lar to that we have described in this case, has been many times taken as the effect of neuralgia and rheumatism. The pain of head was here the first symptom observed, and it coincided probably with the commencement of the disease of the dura mater, and continued as long as the inflammatory process, necessary for the formation of the adhesions described in the post mortem, existed around the tumour, and ceased probably when the adhesions were changed into cellular tissue. The gradual manner in which the paralysis deve- loped itself was conformable to the nature of the disease • it was not preceded by any loss of consciousness, and the intelligence was never disturbed. No lesion explained the incontinence of urine. DISEASES OF THE ENCEPHALIC MEMBRANES. 11 A bright redness of the stomach, and a portion of the intestine, coincided in this case with the adynamic symptoms under which the patient sank.* Case 2.—Osteo-fibrous tumour, of the size of a pullet's egg, on the inner surface of the tentorium cerebelli, to which it closely adheres—Hemiplegia, with convulsive movements at intervals, on the side opposite that where the tumour was—Atrophy of the lobe of the cerebellum, corresponding to the tumour—Death by cerebral hemorrhage. A shoemaker, forty-seven years old, addicted to spirituous liquors, fell on the occipital bone when drunk, about four years before en- tering the La Charite. Immediately after the fall he experienced no uneasiness. Subsequently, however, he began to feel a dull pain towards the left part of the occipital bone, which continued for a considerable time without becoming severe. Giddiness occurred also from time to time, often followed by total loss of consciousness, which never continued, however, beyond a few minutes. At a later period new symptoms presented themselves ; on a sudden the up- per extremity of the right side was attacked with a painful, and as it were tetanic shock. Five or six of these shocks rapidly followed this, and during the three or four days following, the right arm continued torpid and somewhat weaker than that of the opposite side. At first there were intervals of months between these attacks : they then became more frequent, re-appearing every ten or twelve days, uniformly limited to the right arm, and at the same time pa- ralysis of this limb, at first transient, became permanent, and more and more complete. Insensibly also the right lower extremity lost the power of motion ; it never however exhibited any convulsive movement. Before entering the hospital he was attacked with gid- diness, which becoming more severe, determined him on applying for admission. His state then was as follows :— The face and eyes injected ; some difficulty in articulating his words ; answers slow, but correct ; recollection clear ; diplopia from time to time ; commencing deafness. The patient complains of a dull pain towards the back part of the head, on the right side as well as on the left. The two extremities of the right side cannot be moved at the will of the patient; they exhibit however a cer- tain rigidity, and yesterday again the arm underwent five or six shocks, which caused the patient to suffer considerably. Pulse very hard, but not frequent. The pulsation of the heart strong. The muscular system even still remarkably well developed. Just when I had drawn up these details, and we were going to bleed the patient, he was seized with all the symptoms of apoplexy, and died the following day. Post mortem.—In the place ordinarily occupied by the left part of the tentorium cerebelli, there was found a large tumour whieh compressed the posterior lobe of the cerebral hemisphere of this * For some very interesting cases illustrating the effects of pressure from tu- mours, see Dr. Bright's Reports of Medical Cases, vol. ii. part 1. p. 342, &c. 12 ANDRAL'S MEDICAL CLINIC. side, and also the cerebellum. The structure of the cerebral hemi- sphere not changed, the tumour, being principally developed on the side of the cerebellum, the entire left lobe of which had under- gone a most remarkable change, it being very much diminished in volume, and its substance having acquired extraordinary hardness. Neither the cerebrum nor cerebellum were continuous with the tumour. Interposed between them, and evidently produced at the expense of the dura mater, whose place it occupied, this tumour very much resembled that described in the preceding case, except that it contained in some parts a little calcareous deposit. In the right hemisphere of the cerebrum was found an enormous sangui- neous effusion, which, occupying the corpus striatum and optic thalamus, had made its way into the two lateral ventricles through the lacerated septum. The parieties of the heart were hypertro- phied. Remarks.—In this, as in the preceding case, the cerebrum was not all affected ; but one of the lobes of the cerebellum, being com- pressed by it, underwent considerable atrophy. Still none of those functional disturbances, which, according to authors, are connected with lesions of the cerebellum, were here remarked. The symp- toms were just the same as if the tumour were seated in the cere- brum. The development of the osteo-fibrous tumour of the dura mater, seemed to be owing originally to the fall which the patient had suffered several years previously. SECTION II. DISEASES OF THE ARACHNOID AND PIA MATER. There are few diseases whose symptoms present so many varie- ties and so many individual differences as acute inflammation of the meninges. Are there well marked signs, by the aid of which we may readily distinguish duringlife inflammation of the meninges lining the upper surface of the brain from that connected with the lower surface of this organ ? Are there any special functional disturbances appertaining to inflammation of the membrane lining the parietes of the ventricles ? By what signs can we recognise in- flammation of the membranes lining the spinal cord ? Whatever be its seat, can acute meningitis be distinguished by its symptoms, either from the other acute affections of the encephalon, in which this organ is found materially changed, or from those very frequent cases in which irritation of the brain or its coverings, merely sym- pathetic of irritation of some other organ, leaves no trace of its exis- tence in the dead body ? In a word, in the dead body itself, what are the anatomical characters by whose aid we shall be enabled to affirm that there really was acute meningitis in the cases where, during life, symptoms existed which seemed to belong to it ? Such are the questions as yet undetermined in science, in the solution of which we think the following cases will assist. DISEASES OF THE ENCEPHALIC MEMBRANES. 13 CHAPTER I. CASES OF DISEASES OF THE ARACHNOID AND PIA MATER COVER- ING THE UPPER SURFACE OF THE BRAIN. Case 3.—Effusion of blood between the Arachnoid and Dura Mater. A coachman, seventy-three years of age, of a strong constitution, had fallen from his seat nine years previously, and received a deep cut in the left temporal region, for which he was trepanned at the La Chariti. He had not lost his consciousness from the fall, and after it he continued to enjoy perfect health. Towards the 20th March, 1822, he felt, without any known cause, both in the lower extremity and in the arm of the right side, a numbness, with difficulty in moving these limbs, pains also in the elbow and heel ; at the same time vertigo, ringing of the ears, head- ache, and somnolence. The following days there was gradual aug- mentation of these symptoms, and at length he became unable to follow his usual calling. Three days before entering the hospital the motions of the left lower extremity began to be difficult. When he entered the hospital on the 6th of April, 1822, he pre- sented the following state :—obstinate constipation, tongue natural. The two extremities of the right side could still perform some motions, but very feebly ; the left lower extremity was somewhat less weak than the right ; pulse full and strong. Twenty leeches to the neck, friction on the limbs with camphorated spirits. On the 8th,a diminution of the vertigo, headache, and somnolence; had two evacuations in twenty-four hours. Eighteen leeches to the neck, sinapisms to the legs. On the night of this day delirium set in. The following morning less pain of head, but the paralysis more marked. The three following days a gradual increase of the latter. On the 13th the countenance very much injected, drowsi- ness, pain on moving the right arm ; hemiplegia of the left side incomplete, whilst that of the right side is complete ; tongue red and dry, faeces and urine passed unconsciously ; pulse strong and quick ; skin hot and dry (enemata and leeches to the neck, and blisters to the legs with diluent drinks). On the 14th, respiration stertorous ; total loss of consciousness ; coma. He died in the evening. Post mortem.—The arachnoid, thickened and red, was detached from the dura mater of each side by an effusion of blood, partly fluid and partly coagulated, which had completely separated the serous membrane from above downwards, from the part adjoining the great falx of the dura mater to the temporo-parietal suture, and from before backwards, from the coronal fossa to the prosterior end of the parietal. The detachment and effusion were more considera- ble on the left. The depression of the hemispheres was nearly an inch on the left, only half an inch on the right. Beneath the effusion 14 ANDRAL'S MEDICAL CLINIC. the cerebral substance was very firm, and presented very few bloody points, but the sinuses contained a considerable quantity. Remarks.—We have here a rare case of pathological anatomy. It is not easy to conceive how a thin fine membrane, such as the arachnoid is, can be separated from the dura mater by effused blood without being torn. The symptoms here were altogether in relation to the seat and nature of the lesion. The prevailing symptoms existed at first with respect to motion ; there was double paralysis, as there was double effusion. It was not till a later period the intellectual facul- ties became disturbed. The hemorrhage, slowly produced, acted at the same time by compressing and irritating the brain. Case 4.—Effusion of blood between the Arachnoid and Dura Mater—Gradual paraly- sis of the right side with permanent flexion. A man, seventy years of age, of a lymphatico-sanguineous tem- perament and weekly constitution, felt, for the last two months, on the left side of the head, and particularly in the temporal fossa, a constant headache, which went on increasing up to the 4th of May. We could obtain no particular account with respect to the nature of this pain, and the symptoms accompanying it. We only know, that atthe above mentioned period, thepatient beganto stammer,thetongue became embarrassed,the intellect seemed weakened, and in the morn- ing the right side of the body was imperfectly paralysed. This hemi- plegia made very slow progress on the following days. There was added to it continued feverwith adynamic symptoms. When brought to the hospital on the 15th of May, he presented the following state : —Prostration,lyingon his back,pupils equally moveable, countenance very flushed, features drawn to the right, lips dry, tongue red, dry, cleft, trembling, but no deviation to either side ; breath fetid, stools and urine passed involuntarily. Considerable heat of skin, with moisture ; pulse strong, full, and frequent. The extremities of the right side present a paralysis of motion, but not of sensation. To this is added, in the upper extremity, strong contraction of the flexor muscles of the fore-arm on the arm ; the patient seems to understand what is said to him, but he answers very indistinctly. Great drowsiness (two blisters to the right lower extremity, one to the thigh, one to the leg). On the 16th and 17th, gradual increase of the hemiplegia ; the rigidity of the upper extremity continued up to the 20th, when there was observed stupor, stertor, total ex- tinction of intellect (twenty-five leeches to the neck, two sinapisms to the feet). On the 21st the rigid contraction of the right arm ceased, total loss of motion and sensation on the right side, breath- ing stertorous, eyes dull, pupils equally moveable, pulse continually full and strong, skin hot and moist (sixteen leeches to the neck). Died at ten o'clock at night. Post mortem. The vessels uniting the bones to the dura mater appeared very much injected on the left side ; on dividing this mem- brane, we found between it and the arachnoid, along the posterior three fourths of the lateral wall of the cranium, and from its base to DISEASES OF THE ENCEPHALIC MEMBRANES. 15 the falx of the dura mater, an effusion of blood, partly liquid, partly coagulated, black, depressing the serous membrane for nearly an inch at the centre,gradually diminishing in thickness to the circumference. The two folds of the arachnoid were red and thickened. The cerebral substance of the two hemispheres were dotted with blood ; a little serum in the ventricles ; heart very soft and flaccid ; brownish colour of the gastric mucous membrane, towards the great curvature. Remarks.—One of the most curious circumstances in this case is that the symptoms connected with it, very much resemble those occurring ordinarily in softening the brain. Thus, the disease com- mences by a cephalalgia fixed to one point of the head ; then the intelligence becomes impaired ; subsequently the limbs opposite the side of the head affected with pain become gradually weakened, and ultimately the paralysed limbs present a well marked contraction. All these are the signs of softening the brain—still not the slightest trace of this alteration ; nothing being found but a collection of blood between the dura mater and arachnoid, the latter being aiso thickened and diseased. Case 5.—Partial Meningitis—Erysipelatous phlegmon of the neck supervening on a contusion of this part—Signs of arachnitis only during the last hours of life. A postilion, thirty-three years of age, of a strong constitution, received, on the 2d February, 1822, on the right side of the neck, a very heavy sack of oats, which fell on him from a height of several feet. He, however, continued his customary occupation till the 7th. He felt a painful tension on the right side of the neck, at which part the skin assumed an erysipelatous appearance ; fever came on, and the patient kept his room. The fever continued on the 8th, 9th, and 10th, and the erysipelas spread. On the 11th he entered the hospital, when the fever was very high ; the neck was covered with leeches. Desquamation commenced at several points of the skin of the neck ; but on the right, behind the sterno-mastoid mus- cle, an obscure fluctuation was observed ; this muscle also seemed more prominent than that of the opposite side ; no other morbid symptom ; no stool for three days. At one o'clock in the morning the patient suddenly became delirious. On the 12th, at eight o'clock, the delirium still continued ; eyes haggard, constantly roll- ing ; pupils very much contracted ; violent screams ; free motion of the limbs ; pulse frequent and very weak ; tongue moist and red ; burning thirst ; no stool ; some leeches applied the preceding day still bleeding (blister to one thigh, sinapisms to the legs, purging enema, acid drink). Three hours after the visit he expired. Post mortem. Arachnoid and pia mater natural in every respect, except for the space of three fingers' breadth in length, and two in width, near the anterior extremity of the upper surface of the left hemisphere of the brain. There the membranes were thickened and red. A small quantity of limpid serum in each lateral ventricle; the posterior part of the two lungs infarcted ; the mucous membrane of the stomach presented, at the pyloric portion, a slight brownish 16 ANDRAL'S MEDICAL CLINIC tint; the spleen very soft; a great quantity of pus infiltrated the cellular tissue beneath the sterno-mastoid muscle of the right side. Remarks.—This is a very remarkable case. It is probable that the partial arachnitis, ascertained in the dead body, commenced only with the delirium ; the disturbance of the intellect, and a striking contraction of the pupils, were the only two phenomena occasioned by this inflammation ; at times these very slight inflammations of the meninges are sufficient to disturb the intellect. We may note also, that here the inflammation was seated at the anterior and supe- rior part of one of the cerebral hemispheres, where, in fact, several physiologists more particularly place the seat of intellect. But why this contraction of the pupils ? What relation between an irritation so slight, and so well circumscribed, of a very small portion of the meninges, and the movements of the iris ? The nervous centres may then be injured in their functions, without the anatomist being able to discover any alteration. Case 6—Acute Meningitis limited to the convexity of the left hemisphere of the brain —Delirium.—Convulsive movements of the face and extremities of the right side. A tailor, thirty-seven years of age, had been sick for four or five days when he entered the hospital, 17th July, 1821. On the 15th of this month, without any known cause, he was seized with violent pain of head, particularly seated in the frontal region. On the day after, the headache continued, and the pain became more general, being extended now to the parietal [and occipital regions. On this day he lost his appetite, and vomited some drink he had taken. In the evening constant nausea still appeared, followed from time to time by a throwing up of some bitter yellow matter. On the 17th, the headache still continued, but the vomiting ceased ; some nausea still. Having entered the hospital, he presented, on the next day's visit, the following state :—face remarkably pale ; pain of head, the precise seat of which cannot be pointed out by the patient; at inter- vals this became so very severe as to make him utter piercing cries ; eyes dim and languid ; slight involuntary motion of the muscles which move the commissure of the lips ; his answers accurate ; gives a perfect account of his state, and of every thing which happened to him since the commencement of his illness ; the pulse moder- ately frequent, and regular; everything else natural. It was difficult to assign a precise seat to this group of symptoms ; the first complaints, however, regarded the head ; the vomiting might be considered as connected with a commencing cerebral affection, and the severe headache seemed to point out the head as the seat of the disease. The absence of any morbid phenomenon, with respect to the alimentary canal, repelled the idea that the headache was sympathetic of gastro-intestinal irritation. The ab- sence of all febrile disturbance precluded the possibility of its being mere continued fever. The state of the patient, however, appeared very alarming ; the appearance of his countenance, and, amidst this absence of local symptoms, the great alteration already of his fea- DISEASES OF THE ENCEPHALIC MEMBRANES. 17 tures, obliged us to form a rather unfavourable prognosis. M. Ler- minier suspecting a state of encephalic congestion, applied, notwith- standing the extreme paleness of his face, twenty Jeeches across each jugular vein. Demulcent drinks, and sinapisms to the lower extremities. No change in the patient on the following morning. On the 20th, he was very much cast down, and answered ques- tions with difficulty and reluctance ; light was painful to him ; he kept his eyes closed, and his head concealed under the bed-clothes ; face very pale ; pain of head not great ; the convulsive movements of the lips more frequent and more marked ; pulse and skin natural (blister to the nape of the neck). In the night he emerged from a state of stupor, in which he had been for the last twelve hours.— He got up out of bed suddenly, saying that some persons were pur- suing him to do him harm. He raved during the night, and occa- sionally uttered several piercing cries. On the 21st, he was kept in bed by force. The face had now become red ; the head was agitated by a continual movement, which carried it from right to left, and left to right: the muscles moving the lips, the alae nasi, and the eyebrows, were in the highest degree of convulsive agitation ; saliva, slightly frothy, flowed in great abundance from the mouth ; he spoke incessantly and with energy, but his articulation was unintelligible ; great subsultus tendinum, which prevented the pulse from being felt ; its frequency did not seem very great (bleeding from the arm, twenty leeches to the neck, cold applications to the head). No change on the 21st. On the 22d, violent delirium ; convulsive motions of the mus- cles of the face : risus Sardonicus ; continual motion of the right arm ; subsultus increased ; pulse more frequent; tongue moist and red (two blisters to the thighs ; ice to the head). On the 23rd, head turned back, and to the right; strong contrac- tion of the right arm ; respiration very irregular ; occasionally accelerated ; it then becomes slower than natural. The patient silent and quite still ; eyes fixed, and void of expression ; mouth open and unmoved ; pupils neither contracted nor dilated ; answers no questions ; does not even seem to understand them ; original paleness of face returned ; pulse sixty a-minute, and regular ; bowels not free ; tongue cannot be seen ; teeth not dry. He remained quite torpid during the day, but at night violent delirium reap- peared ; uttered very loud cries. On the 24th, this excitement was succeeded by profound coma ; extremities cold ; a clammy sweat covered the face ; respiration rattling. Died in the course of the day. Post mortem.—On the upper surface, a considerable difference in the colour of the two cerebral hemispheres, the right being pale, whilst the left presented a well-marked red tint, which resided entirely in the subarachnoid cellular tissue, which was traversed by numerous vessels ; neither serum nor pus in this tissue ; the grey substance constituting the most superficial portion of the convolu- tions of the left hemisphere participates in the injection of the pia Sept. 1838.— K 4 18 ANDRAL'S MEDICAL CLINIC mater covering it. The ventricles contained scarcely two tea spoon- fuls (cuillere'es a cafe") of serum ; nothing remarkable in the rest of the brain. The lungs infarcted posteriorly ; the heart contained in its right cavity a large fibrinous clot, deprived of its colouring matter ; the mucous membrane of the stomach very thin towards its great curvature. Remarks.—This case presents an example of acute meningitis more extensive than the preceding case, but still partial; it occu- pies, in fact, but one of the sides of the brain, the median line accu- rately limiting it. The first symptom was pain of the head, which was of long duration and remarkably severe. This, after a little, was complicated with gastric symptoms, which appeared entirely the sympathetic result of the brain affection. The nausea and vo- miting arose from the disturbance of innervation, but these sympa- thetic phenomena soon disappeared. The brain symptoms gradually became worse. The intellect, also, so perfect when he entered the hospital, became gradually disturbed. The slight convulsive move- ments of the lips were soon succeeded by convulsions of the entire face and of the right arm, which latter was ultimately found to be permanently flexed. This disturbance in the motion of the right arm might cause us to anticipate that the opposite side of the brain was the seat of the disease ; the pain of head not being confined to the affected part of the cerebral membrane, could not assist in deter- mining it. The therapeutic means adopted seem to have had no influence whatever on the disease. A little more blood than natu- ral, accumulated in a circumscribed portion of the pia mater, was enough to destroy the nervous functions, and ultimately life. Case 7.—Meningitis limited to the anterior extremity of each cerebral hemisphere— Rosy tint and slight softening of the subjacent grey substance—Follicular enteritis proceeding towards a cure—Symptoms of ataxic fever. A boy, seventeen years of age, entered the hospital February 18th, 1S24, with symptoms of slight continued fever ; headache ; tongue white, moist, slightly red at the point and edges ; thirst considera- ble ; constipation ; no change in his state for the five or six days fol- lowing, during which interval he was bled from the arm, and twenty leeches were applied to the anus. On the 24th, we were struck with the air of distraction in the patient's countenance ; he answered questions with difficulty, and appeared to be absorbed in thought. On the 25th, he was sunk in stupor ; pupils perceptibly dilated ; tongue natural ; pulse small and frequent; skin hot (twenty leeches to the neck). During the two following days no change. On the 28th he emerged from the stupor, became restless, and spoke continually. March 1st, stupor returned ; dilatation of the pupils extreme ; tongue quite natural ; pulse very small and frequent; notwithstan- ding the torpid state of the patient, the cutaneous sensibility was very much increased ; he complained whenever we touched the DISEASES OF THE ENCEPHALIC MEMBRANES. 19 skin, particularly on the thorax and abdomen ; he pushed the hand which touched him, and complained of pain (leeches again to the neck, and blisters to the legs). He died the next night. Post mortem.—Fulness of the veins traversing the convexity of the cerebral hemispheres ; the portion of the pia mater covering the anterior extremity of each of the hemispheres very much injected ; rose-coloured tint, together with slight diminution in consistence, of the cortical substance in contact with the pia mater at this part of the brain. No other appreciable alteration in any part, except that the lungs contained some small granulations not resembling those usually met with, which, when cut into, allowed a small quantity of limpid serum to escape. The inner surface of the stomach was very white, except one small spot, which was red, and seemed formed by the aggregation of small vessels finely injected. In the small intestines several of the follicles were more developed than natural ; some single, and others aggregated together, constituting what are called Peyer's glands ; they presented black points, and projected some- what beyond the level of the mucous membrane. Remarks.—This is another case where inflammation of the mem- branes existed only in a very small extent of the external surface of the brain. The pia mater was injected merely towards the anterior and upper part of each hemisphere ; and in this part the grey sub- tance of the circumvolutions participated in the irritation of the membrane covering it. This is all that was found to explain the serious nervous disturbances which manifested themselves on the last days of the patient's life. No doubt but the patient died in consequence of the lesion of the nervous centres. The entire disease, however, did not reside here ; for, on entering the hospital, nothing manifested itself but mere continued fever, without any well marked local symptom ; the intestine was then diseased, and we doubt not but that, at first, there was follicular enteritis, which was in progress of cure, as appeared from the post mortem ; then the partial menin- gitis supervened, which rapidly gave the most serious character to a disease till then mild. Case 8.—False membranes of recent formation on the arachnoid, lining the convexity of the left hemisphere—No other appreciable lesion of the meninges—Headache at the outset—Delirium—Tubercles in the lungs and spleen. A man, forty-three years of age, entered the Hospital la Pitie at the commencement of the month of April, 1831, presenting the ordinary symptoms of pulmonary phthisis. On the 19th of May he complained of an acute pain, seated in the left temporal region.— This pain, which was not increased by pressure, became occasionally insupportable, and then radiated towards the parietal and orbital regions of the same side of the head. This was the first time he complained of such a pain ; it had appeared the night previous, and prevented him from enjoying a moment's sleep. No other change in the state of the patient; the pulse was, as we usually found it in the morning, from 70 to 80 ; no appreciable disturbance in sensa- 20 ANDRAL'S MEDICAL CLINIC. tion or motion. This pain, then single, and unaccompanied by any other symptom, was considered mere temporal neuralgia, and nothing particular was prescribed. However, the following day and night the patient suffered dreadfully in the temporal region.— On the :20th of May, though seeing no reason to change our diagnosis, we had him bled from the arm to twelve ounces ; the blood, exam- ined the next day, consisted of a small clot, rather black, without any appearance of the buffy coat, and encompassed by a great quan- tity of serum. The pain of the left temple had not diminished ; no other new symptom manifested itself. On the 21st, still headache ; no change at all ; twenty-four leeches were applied to the left mas- toid process, which bled freely ; but the headache is as intense as ever. Conceiving the affection to be a neuralgia, we applied an opium plaster to the left temple, and ordered a grain of hyoscyamus to be taken internally. On the 23rd, 24th, and 25th of May, no change ; but on the 26th we remarked, for the first time, that the skin of the two eyelids, as also those of the cheeks, was raised by serum accumulated in the cellular tissue ; this skin preserved its natural colour ; headache continued ; the pulse was, as usual, 80 ; a blister was applied to one of the lower extremities. On the night of the 27th, the intellect disturbed for the first time ; he arose from bed, and became very noisy. Towards morning the delirium ceased, and at the visit we found him as usual, except that he complained less of the temple. On the night of the 28th, the intellect again disturbed, and delirium returned ; in the morning he answered questions very incoherently ; the cedema of the face increased, without the skin being red ; pulse 88, and the tempera- ture of the skin raised. In the course of the day the patient became comatose, and died on the 29th. Post mortem twenty-nine hours after death.—The cranium being raised, and the dura mater divided, we found covering the convexity of the left hemisphere of the brain, at the point of union of the middle and anterior lobes of this hemisphere, a whitish false membrane, soft and not yet presenting any character of organisation, and merely in apposition with the arachnoid, to which it did not adhere. This false membrane was somewhat broader than a dollar. On other points of the arachnoid, of the same side, there were depo- sited as it were small drops of white, thick pus, which we raised on the back of the scalpel. Two or three such drops were found on the portion of the arachnoid covering the left surface of the great falx cerebri ; no other appreciable alteration in the arachnoid or brain. In the thorax were numerous tebercular masses, some of which were softened. The internal surface of the stomach pre- sented a slate-colour tint, with papillary thickening of the mucous membrane along the great curve. About a quarter of the spleen converted into a large tubercular mass. Remarks.—This is one of those rare cases wherein the arachnoid properly so called, is the seat of the disease. It is in fact in its cavity that the morbid products existed. On the right every thing DISEASES OF THE ENCEPHALIC MEMBRANES. 21 remained in the most natural state. It is a case of real arachnitis, similar in every respect to inflammation of serous membranes else- where. This inflammation of the arachnoid will easily explain the different nervous symptoms during life. Thus the pain which affected the left temporal region so long and so severely, was not a mere neuralgia. It marked the commencement of the arachnitis, and for a long time continued alone, and it was only towards the end, that more decided symptoms of arachnitis appeared, first deli- rium and then coma, which was followed by death. Case 9.—Partial meningitis—Tubercles in the pia mater, and in other organs; adhe- sions of two circumvolutions—Headache at first; afterwards delirium; contrac- tion of the muscles of the neck ; paralysis of some muscles of the face. A man, nineteen years of age, on entering the La Charite, com- plained of a violent headache, principally seated towards the right temple, under which he has been labouring now twelve days. His intellect perfect ; he constantly lies on the left side. Pulse slow (sixty a minute); the pupils a little dilated ; countenance expresses an air of indifference ; tongue natural ; has some difficulty in pas- sing urine. This group of symptoms make us apprehend the deve- lopment of a cerebral affection ; he was ordered to be bled from the foot, and forty leeches to be applied to the neck. The day after (14th March) the air of indifference was succeeded by complete delirium ; the head remained constantly inclined to the right; pulse now seventy-two. He was bled from the arm. In the evening he can now answer questions tolerably, which he could not in the morning. When we attempt to incline his head to the left, he evinces pain ; the right side of the mouth then opens, whilst the left half remains unmoved. March 15th. Look fixed ; head still inclined to the right ; deli- rium still continued ; air of stupor ; pulse more frequent than on the preceding days ; tongue natural ; abdomen free from pain ; no evacuation by stool (thirty leeches to the neck, laxative enema).—•■ Whilst the leech-bites were still bleeding, the pupils, which till then had remained dilated, contracted in a very remarkable manner. The pulse became very frequent, irregular, and small ; the mouth became filled with foam ; the tracheal rale set in, and the patient died at half-past twelve at noon. Post mortem.—The pia mater covering the upper surface of the cerebral hemisphere, contained about twelve small whitish granu- lations, the size of a lentil, and of cartilaginous consistence. They were found between the convolutions. On the middle lateral part of the right hemisphere, was observed a bright red injection of the pia mater, for a space as large as two five-franc pieces put together. Between two circumvolutions of the middle lateral part of the left hemisphere, was found a white tubercle of the size of a large pea, soft- ened at its centre. These two convolutions had contracted intimate adhesions, and were confounded with each other. Numerous tuber- cles in a crude state traversed the lungs. The lymphatic ganglions r 2o ANDRAL'S MEDICAL CLINIC. of the posterior mediastinum also tuberculated. Three small tubercles in the spleen. Remarks.—Of the alterations found after death in the body of this patient, some were dated from a period long prior to the attack of the disease under which he fell. Such were the tubercles in the pia mater, in the lungs, in the lymphatic ganglions of the posterior mediastinum, and in the spleen. The adhesion also of the two convolutions of the left hemisphere was a lesion of long standing, and prior to the disease observed by us ; to explain the latter, then, we have but the injection of the pia mater in a very small portion of its extent, without any other alteration of this membrane, or of any other part of the encephalon. When the lesions were so slight and the symptoms so severe, who would dare to affirm that these lesions represented everything that did exist, and that anatomy showed us everything that was materially altered in the nervous centres ? Certain it is that the only appreciable alteration of recent formation, discovered on opening the body, existed in these centres ; and it was here also during life, that the entire disease seemed to reside. For a considerable time it appeared unattended with any- thing serious ; and obstinate headache, situated towards the point where, after death, we found the pia mater injected, was for the first twelve days, the prevailing symptom. When we saw the patient, his intellect was perfect, his faculties of motion and sensa- tion were unimpaired, and he had no fever. Still from the very first we were struck with his position when in bed, and this phe- nomenon added to the air of indifference expressed in his counten- ance, directed our attention to the brain. On the following days the disease, which had been at first mild, was accompanied by most marked and alarming nervous symptoms. Delirium, partial paraly- sis of the muscles of the lips, painful contraction of the muscles of one side of the neck, particularly engaged our attention. Whilst these phenomena were developing themselves, the pulse became accelerated, the tongue preserved the most natural appearance. In this case the most active antiphlogistic treatment was employed. During the three days the patient remained in the hospital, he was bled twice, and seventy leeches were appled to his neck. Still the most serious symptoms supervened every day, and we shall even remark, at least as a mere coincidence, that it was immediately after the application of the last leeches that the struggle commenced. Had the loss of blood any share in the symptoms which appeared during the last hours of life ? we should be inclined to think it had. Case 10.—Milky infiltration of the pia mater on the upper surface of the cerebral hemispheres—Turbid serum in the great cavity of the arachnoid—Suppuration of the pituitary gland—Vegetations on the aortic valves, with production of encephaloid matter at their base— Delirium—Hurried respiration—Pleurosthotonos. A man, sixty-four years of age, was brought to the La CharitS M?,the ?7t,h of,May- Those who brought him stated that he was ill for the last fourteen days, but gave no other information regard- DISEASES OF THE ENCEPHALIC MEMBRANES. 23 ing him. On the next day he presented the following state :— Countenance very pale and dejected ; lies on his back ; oedema around the ankles ; delirium ; complains continually ; voice weak and trembling ; respiration high, hurried, very painful, as if there were some obstacle to the free entrance of the air into the pulmonary vesicles; no lesion, however, detected by auscultation in the lungs; the air appears to penetrate in every part; the pulse, being very small, contrasts with the strength of the pulsations of the heart, which are accompanied with a well-marked bellows sound ; tongue natural ; abdomen soft (diluent drinks, sinapisms). On the 29th, his entire body strongly inclined to the right : the muscles of the neck, and those of the trunk of the same side, being spasmodically contracted, prevented the neck and head from being brought into the straight position ; still less could they be made to deviate to the left. To these symptoms of pleurosthotonos were joined delirium, great dyspnoea, extreme frequency of the pulse, which was at the same time thready. Died at noon. Post mortem.—Body very much emaciated ; oedema of the lower extremities. Cranium.—The great cavity of the arachnoid contained a con- siderable quantity of milky serum ; the pia mater lining the upper and lateral surfaces of the cerebral hemispheres was infiltrated with liquid similar to thick cream ; no trace of the pituitary gland to be found in the sella turcica ; in its place there was a collection of pus.* Thorax.—Lungs and pleurae sound ; a little serum in the pericar- dium ; right cavities of the heart distended by an enormous clot of blood ; one of the aortic valves had, on its ventricular surface a greyish vegetation, easily detached with the scalpel from the tissue on which it rested ; another of the aortic valves had entirely lost its usual appearance ; it was changed into a reddish mass, and towards its point of union with the internal membranes of the vessels, the latter presented an evident fluctuation ; a slight incision was made on the point where this fluctuation existed, and there escaped between the lips of the incisions a chocolate coloured matter, of a softish consistence, like a mixture of blood and cerebral matter. It is more probable that this was blood effused and altered, than the result of a morbid secretion. Remarks.—In this case, which we had not the opportunity of seeing till a very advanced stage, the membranes were more seri- ously affected than in any of the preceding. First, they were changed to a greater extent; then there was not only hyperemia, but purulent secretions on the two surfaces of the arachnoid, and, what is most unusual, suppuration of the pituitary gland. The symptoms first observed were those usually accompanying meningitis of the convexity of the hemispheres. How shall we t * From the situation of this organ, which is such as to prqtect it from injury, it is probable that there are some very important functions assigned to it, with the nature of which we are totally unacquainted. Considerable importance has been attached to it as connected with epilepsy. Dr. Bright mentions a case, vol. ii. p. 301, where it was wanting. 24 ANDRAL'S MEDICAL CLINIC. account for the pleurosthotonos, whilst the lesion of the membranes was the same on the right and left ? The principal cause of the difficulty of respiration appears to have been the alteration of the siomoid valves of the aorta. This was probably the cause of the bellows sound. Case 11.—Purulent infiltration of the sub-arachnoid cellular tissue of the upper and inner surface of the two cerebral Hemispheres—Bright red injection circumscribed to the middle lateral portion of the left hemisphere—Tubercle in the brain—Pain of head; hemiplegia of the right side; dulness; vomiting; infrequency of pulse. A boy, seventeen years old, felt for the preceding fifteen days vio- lent pains of the head, and experienced for the last two days only commencing weakness in the lower extremity of the right side, when he entered the hospital on the 24th July 1822. His state then was as follows :—Countenance very pale, slightly puffed : pupils natural ; vision and intellect perfect ; the lower extremity of the right side seems to the patient heavier than the left. Since the preceding night only he began to feel some difficulty in moving the upper extremity of the right side, and it seems heavier to him than the other ; the sensibility of both these limbs, however, is un- impaired ; pain of head very acute, and occasionally extorts loud cries from the patient ; pulse irregular, but not frequent; respiration laboured, and the intervals between each inspiratory movement unequal (twenty leeches behind each ear, sinapisms to the legs). A few hours after the visit the patient fell into a profound stupor. The following morning, 25th July, the coma disappeared ; intellect perfect; answers precise ; pain of head continues ; paralysis of the right side increased ; pulse very irregular, and fifty each minute ; vomited a green bitter matter twice or thrice during the night ; tongue still the same (thirty leeches to the neck, two blisters to the legs). On the visit of 26th sunk into a profound coma ; his coun- tenance, however, indicates pain, when the limbs are pinched ; pulse preserves its slowness and great irregularity ; skin cool and moist (a blister to the nape of the neck). On the 27th, eyes open, but immoveable ; vision appears to be gone ; he seems not to understand any thing ; and articulates not a word (stimulating frictions to the limbs ; ice to the head : sinapisms to the legs). On the 28th, pulse ninety six. On the 29th, other symptoms appear ; the eyes and face are become the seat of slight convulsive twitches, which are repeated at short intervals ; coma not increased ; he stares at those questioning him, without answering ; distinguishes objects well ; complains very much ; retracts the arm a little when it is pinched this arm when raised falls as an inert mass, whilst he holds the left arm raised without any effort; pulse eighty ; the respiration propor- tionally more accelerated than the circulation (ice to head conti- nued). On the 30th,the intellect returned, the patient answers ques- tions, hears and sees perfectly ; pulse ninety-two, and the respiration still accelerated ; paralysis of the right side continues. On the 31st, the patient, whose state for the last two days was so perceptibly DISEASES OF ;THE ENCEPHALIC MEMBRANES. improved, relapses into coma ;, during the day the respiration, which is now accompanied witharattle,becomes moreand more accelerated, and the patient expired, as if in a state of asphyxia, during the night. Post mortem.—The pia mater covering the upper surface of the two hemispheres was infiltrated with a thick purulent layer ; the arachnoid itself being in its natural state. On the left, below the pia mater, near the great interlobular fissure, several circumvolu- tions present a bright red appearance ; some even present a uniform red tint; the tissue of the circumvolutions in other respects natural ; outside the left lateral ventricle, on a level with the ancyroid cavity, the cerebral substance contains a tubercle the size of a large pea, developed in a mass of grey substance. Tubercles were found in great numbers in the two lungs. Remarks.—In this case the membranes were not only injected, they were also the seat of purulent secretion. One of the most striking of its symptoms was the paralysis of one side of the body, which developed itself from the commencement of the disease, and went on increasing. It seemed as if the left hemisphere of the brain was subjected to some compression, and yet such did not appear. The purulent layer between the arachnoid and brain was on both sides ; on the left only some of the circumvolutions participated in the irritation of the membranes, inasmuch as they were considerably injected. If that were the cause of the paralysis, why was it not preceded by a state of contraction of the limbs, as happens very often in inflammation of the cerebral pulp ? Beside this permanent symptom we find others remarkable for their appearing and disap- pearing alternatively ; thus the intellect went and returned ; the very evening before death it was quite perfect ; still it is very pro- bable that these lesions in the pia mater, which we discovered the following day, existed at that time. Several times also the patient fell into a state of coma, which is considered as appertaining to inflammation of the meninges covering the lower surface of the brain ; and this coma was also moveable as the delirium. The sight also went and returned. Was it not strange that these func- tional disturbances were but transient, whilst the lesions causing them were permanent ? In such a case it must be admitted that these symptoms depended less on the cerebral membranes them- selves than on the way in which the cerebral pulp was affected at different periods of the disease by the irritation of the membranes enveloping it. Thus in pericarditis the variability, mobility, and oftentimes also the transient nature of the symptoms depends on this, that the heart in all persons, or in one and the same person, during the entire course of the disease, is differently affected by the irritation of its investing membrane.—No alteration in the pul- monary parenchyma, nor in its investing membrane accounted for the very great disturbance of the respiration that was observed.-— The symptom, as also the vomiting that took place, must have depended on the cerebral affection. 26 ANDRAL'S MEDICAL CLINIC. Case. 12.-Abuse of spirituous Hquors-Pleuro-pneumonia at theL°u^~^br^ ££ rium-Employment of opium in a large dose-Purulent infiltration of the sub- arachnoid cellular tissue of the convexity of the hemispheres. A coachman, forty-eight years of age, addicted very much to alcoholic liquor, was received into the La Chantt on the 25tn 01 September. He then complained of a pain below the left mamma. On the posterior and inferior part of this side, a well marked crepi- tating rattle was heard, and the sound in this part also was dull. The patient coughed frequently, and expectorated transparent viscid sputa, which were slightly streaked with blood. He had considera- ble fever. Three days previous, this person, being till then in good health, was seized with a violent shivering; then pain ot side, oppression,and cough became manifest. These symptoms ot pleuro- pneumonia were irTet by bleeding from the arm to sixteen ounces, and the application of twenty leeches to the side, which was done immediately after the bleeding. The blood taken from the veins exhibited the buffy coat. On the following day there was an evi- dent amendment. On the night of the 26th the patient was suddenly seized with delirium. On the 27th, the delirium still cont.nued ; the general symptoms of pleuropneumonia were gone. Fever still. He was bled to twelve ounces ; blood buffed. His state on the 28th still the same (thirty leeches to the neck). On the 29th, delirium still continued. Guided as well by the exis- ting symptoms, as also by knowing the previous habits of the patient, we began to suspect that the case was one of delirium tremens ; we determined to try opiates, and ordered ninety-six drops of Rous- seau's laudanum to be given in two doses. He took the first with- out any perceptible effects ; in two hours after he took the other, and soon fell into a tranquil sleep till the following morning. He awoke at the visiting hour, and answered, with precision, the ques- tions addressed to him, and again fell asleep ; he awoke in the after- noon in the full possession of his reason. On the 1st of October there was considerable fever, which was accounted for by pulmo- nary engorgement, detected in the posterior and left side of the chest, the crepitating rattle being distinctly heard here ; the use of opiates was suspended. On the 3rd, the crepitating rattle was still heard, and in the evening the fever was much increased. On the 4th, the pulse very frequent, and a tendency to delirium re-appeared ; two blisters to the legs. However, in the course of the day, all tendency to delirium disappeared, and the pulse became less frequent. For three days following the intellect became sound, and every thing so favourable, that he appeared likely to be able to leave the hospital very soon ; when, on the 9th, his intellect again became disturbed, and the pulse was somewhat accelerated ; upon which, an anodyne potion, containing a scruple of laudanum, was prescribed ; two blisters were applied to the thighs, and sinapisms to the lower extremities, but without any benefit. On the 17th, 18th, and 19th, the delirium became complete. On the 20th, the tongue for the first time, lost its natural appearance ; it became red and somewhat DISEASES OF THE ENCEPHALIC MEMBRANES. dry. The seven days following, continual delirium, increasing pros- tration ; tongue dry and brown ; fasces passed involuntarily ; pulse frequent and small; rapid emaciation of the face. He died on the 27th of October. Post mortem.—A turbid milky serum infiltrated the sub-arach- noid cellular tissue of the convexity of the hemispheres in conside- rable quantity. The lateral ventricles contained but a small quan- tity of limpid serum. In the thorax, cellular bands closely united the pleura costalis, and pleura pulmonalis of the left side. A great quantity of frothy serum gushed out of the tissue of the two lungs ; this tissue also retained the impression of the finger like an oedematous limb. The pericardium adhered closely to the heart by a dense cellular tissue, whose formation must have been anterior to his entering the hospital. Nothing particular in the abdominal viscera, except that the splenic portion of the stomach was conside- rably dilated, and the pyloric portion contracted. Remarks.—When the patient entered the hospital he presented all the symptoms of pleuro-pneumonia, except the characteristic sputa, which were wanting, as sometimes happens. Active anti- phlogistic treatment soon dissipated all the symptoms except the crepitating rattle, which was still heard. Delirium then set in, which was met by venesection, leeches to the neck, and revulsives to the lower extremities. To relieve this state, one hundred drops nearly of Rousseau's laudanum were administered, a mode of treat- ment oftentimes found beneficial where delirium comes on suddenly, in the course of another disease, in persons habitually addicted to ardent spirits. The result was favourable ; the patient obtained calm sleep, from which he awoke with his intellect quite sound.— All fever also disappeared ; he now seemed convalescent. Again, however, without any known cause,the delirium and fever returned, and an opiate was again employed ; but whether from its being given in too small a dose, or that the functional disturbance was now beyond the reach of opium, the cerebral symptoms continued to become worse, and, seven days after their reappearance, the patient died. It was not probably during these seven days that the morbid alter- ations in the meninges were formed. The pia mater had certainly been the seat of inflammation. Was it so, when the delirium ceased so readily after the first opiate was given ? We know that opium has, under ordinary circumstances, the property of exciting cerebral congestion, or, at least, that it produces symptoms which are accounted for by such congestion. We know nothing positive regarding the nature of the lesion existing in the brain, or its mem- branes, on the first appearance of the delirium ; nor is it necessary to believe, that congestion is necessary to produce such a symptom ; as we know from the postmortem examinations of several whp, during life, had the same symptoms as this individual, and yet no lesion was found to account for them. We think, that in such cases, there supervenes, in the nervous substance, a modification, 28 ANDRAL'S MEDICAL CLINIC. whose anatomical sign escapes us, which precedes either the conges- tion, or the other alterations, which constitute the anatomical char- acters of encephalitis or meningitis. May not opium, which is mischievous when once the congestion is established, be then administered, inasmuch as, the brain not being in its normal state, the opium loses the power of producing congestion in it ? We think it likely that, if the opium had been administered the second time in as large a dose as at first, on the re-appearance of the deli- rium, it would have again succeeded in removing the nervous symp- toms. Case 13.—Serous cyst developed in the pia mater—Great quantity of turbid serum in this membrane—Hemiplegia at the age of eight years, which completely disap- peared at puberty—Atrophy and debility of the limbs formerly paralysed—Cancerous ulcer of the stomach. This was the case of a man seventy-two years old, who, at the age of eight years, was struck with paralysis of the limbs of the left side, which remained till puberty, and then gradually disappeared ; these limbs continued, for the remainder of his life, much less deve- loped and feebler than those of the opposite side. He also usually experienced in them a sensation of cold. For the last four years of his life his digestion became very much deranged, and he lost all appetite, and without any pain of head or any other part, he gradu- ally wasted away, and died in a state of extreme emaciation. Post mortem.—The sub-arachnoid cellular tissue of the convexity of the hemispheres was infiltrated with a considerable quantity of turbid serum, and on removing the membranes, the circumvolutions of the two hemispheres appeared farther separated than ordinary, by the great quantity of fluid filling up their anfractuosities. Near the great interlobular fissure, towards the middle part of the right hemi- sphere, there was found in the midst of the sub-arachnoid cellular tissue, a serous cyst, about the size of a small apple, which depressed the cerebral substance beneath it. An enormous quantity of frothy colourless serum flowed from the right lung when cut into. The mucous membrane of the stomach presented, at the distance of about three fingers' breadth from the pylorus, a rounded ulcer, about five inches in diameter, the edges of which, formed of mucous mem- brane, were of a livid red colour. In two or three places the parie- tes of the stomach were perforated by this ulcer, and the pancreas was exposed. Remarks.—The serous cyst developed in the pia mater, was here no doubt the result of the lesion which had been in his early life the cause of the hemiplegia in this individual. There was no disturbance of the intellect observed at any period of the patient's life, which circumstance may be accounted for by the slow manner in which the effusion took place.* * The fourteenth case given by Andral resembled the above very much, with respect to the anatomical lesions found in the encephalon, except that instead of one, there were several cysts discovered. Yet the symptoms differed consi- DISEASES OF THE ENCEPHALIC MEMBRANES. 29 CHAPTER II. DISEASES OF THE MENINGES OF THE LOWER SURFACE OF THE BRAIN. Case 15.—Purulent infiltration of the pia mater covering the lower surface of the brain—Turbid serum in the inferior occipital fossae—Delirium at the commencement of the disease; subsequently profound coma—Pulmonary tubercles. A tailor, twenty-seven years old, had been for three weeks in the hospital, with all the symptoms of advanced phthisis, when one morning we were struck with the indistinctness of his answers ; in fact, he seemed as if drunk. The pupils were strongly contracted, and there was great febrile disturbance ; on the following morning he presented the following state ; head turned backwards, nor could it be brought forward, without eliciting screams from the patient ; pupils very much contracted ; makes no answers ; occasionally raves ; some froth at the mouth ; teeth closed as in trismus ; pulse more than one hundred and twenty ; skin hot (two blisters to the legs). For the four following days the retroversion of the head, and the closing of the jaws, disappeared ; the two pupils remained con- tracted ; on raising the eyelid, we thought the sight quite gone ; he seemed plunged in a profound sleep, scarcely drew back his limbs when pinched. Pulse now but of moderate frequency ; skin not very hot, was almost constantly covered with abundant perspiration. The tongue never changed from its natural appearance. The coma however became more and more profound ; the respiration became embarrassed, and the patient expired as in a state of apoplexy. Post mortem.—We found the entire lower surface of the cerebral hemispheres covered by a thick layer of concrete pus contained in the pia mater ; it was found in great quantity, particularly in the fissure of Sylvius, and around the thalamus of the optic nerves.— Five ounces at least of milky serum were effused between the cra- nium and lower surfaces of the cerebellum. Numerous tubercles in different states existed in the lungs. Remarks.—One could not have announced from the symptoms during life, that the membranes at the base of the brain were the exclusive seat of the disease, as nearly similar symptoms were ob- served to exist in cases where the meninges of the upper surface were engaged. MM. Parent du Chatelet, and Martinet have given coma as the distinguishing characteristic of meningitis of the base. But this symptom has been observed in cases where the meninges of the convexity were affected. The absence of headache could not be accounted for by the seat of the affection, as the same absence was derably, the intellect being disturbed in the latter case, whilst the power of motion was affected in the other. May this diversity of symptoms, he asks, be explained by the difference in the intensity of the pressure to which the brain was subjected in the two cases'?—T. Sept. 1838.—L 5 30 ANDRAL'S MEDICAL CLINIC. observed where the membrane of the convexity was the seat of inflammation. Neither can the contraction of the pupils be con- verted into a sign, as in diseases precisely similar, both in their seat and apparent nature, the pupils have been observed sometimes con- siderably dilated, sometimes strongly contracted, and sometimes in the natural state ; and occasionally contracted on one side and dilated on the other. Acute meningitis is very rarely observed to accelerate the death of phthisical patients. Some of them, to be sure, become delirious a little before death ; but no lesion of the brain or its membranes has been detected to account for this symptom. Case 16.—Intense headache with vomiting at first—Tendency to sleep, and disincli- nation to move—Gradual establishment of coma—Natural state of the pupils—Puru- lent infiltration of the pia mater of the base of the cerebrum and cerebellum. A labouring man, of middle age and strong constitution, on entering the hospital complained of nothing but violent headache, which com- menced five or six days previous, and was for the first two days ac- companied with a painful vomiting. The temples were the seat of the pain; they seemed as if compressed in a vice ; at intervals he felt acute lancinating pains either at the temples or the occiput, and oc- casionally the back of the neck became so painful that the patient could not move : he then presented all the symptoms of wry-neck —he felt easy only when perfectly at rest; appetite gone ; and what he ate, he said, gave him no strength ; since the invasion of the headache had been but once at stool. We saw him first on the 3d of July, when he presented the following state ;—Face pale and dejected ; look quite vacant ; eyes very sensible to strong light ; intellect clear ; pulse and skin natural. The headache the only im- portant symptom in this case (bleeding to sixteen ounces ; sina- pisms to legs ; purgative clyster) ; the blood formed into a soft coagulum, with little serum,and no buff. 4th July. He complained aloud of the violent pain of head ; he fancied his skull beaten in as it were with a hammer. Still his forehead was cool, and his face paler than the day before ; the pupils, intellect, circulation, natural. Thus the bleeding produced no diminution of the headache—(a se- cond bleeding). On the 5th thirty leeches were applied to the neck. On the 6th headache less ; but he answers questions with difficulty; he lies on his back and remains motionless, and resembles a person going to sleep, or whose eyelids are struggling against sleep. He still retains his intellect, but appears to use it in spite of himself; countenance very pale ; features drawn, and as it were fatigued. (Two blisters to the legs.) On the 7th he appears in a profound sleep, will not answer questions ; when bid he puts out his tongue readily, which remains white and moist. On being pinched he shows that he still retains all his sensibility ; pupils sensible to light; pulse sixty ; heat of skin natural. 8th and 9th. Profound coma ; he refuses to open his eyes, and appears not to hear the questions put to him ; pupils natural ; some sensibility still retained (strong sinapisms to the lower extremites). On the 10th. Coma DISEASES OF THE ENCEPHALIC MEMBRANES. 31 still ; complete loss of sensibility ; yet, notwithstanding this anni- hilation of the functions of the life of relation described by the an- cients under the name of lethargy, the functions of organic life are still perfect; pulse, temperature of skin, and respiration, natural. On the 12th, for the first time, the respiration appeared affected ; sometimes very much accelerated, at other times so slow that the respiratory movement just made, seemed not likely to be succeeded by another. On the 13th. Respiration still accelerated ; in the course of the day the tracheal rattle set in, and the patient died in the night. Post mortem.—The upper part of brain and meninges being minutely examined, no morbid appearance was detected ; but on examining the lower surface, the pia mater covering it was infiltrated with a purulent layer from seven to eight lines thick. Chest.—Lungs very much engorged, as the lungs of apoplectic patients, or of animals who die a certain time after a division of the pneumo-gastric nerves ; the right cavities of the heart distended with clots of considerable consistence ; the left cavities empty. Remarks.—In this case and in the preceding the leisons found in the dead body were similar, and had the same seat; yet, how dif- ferent were the symptoms in both cases ! In the latter case, the seat of the headache was far removed from the place where the autopsy detected the leison. The several bleedings seemed to exer- cise no influence on the pain in the head ; a little after them, the patient, without any previous disturbance of intellect, fell into a state of coma, which every day became more and more profound. Up to the end the pulse continued natural, and it was only towards the termination that the respiration became disturbed, and death seemed the immediate result of the disturbance of this function. The slight disturbance of digestion was but sympathetic. The vomiting, which showed itself at the same time as the pain of head, seemed of the same nature as that which so frequently accompanies the acute hydrocephalus of children, depending equally on disturbance of the nervous centres. The constipation observed in this case is an ordi- nary symptom when the brain is affected. CHAPTER III. DISEASES OF THE MENINGES COVERING THE PARIETES OF THE VENTRICLES OF THE BRAIN. The cellulo-vascular web extended over the parieties of the lateral ventricles is not visible in the natural state, but becomes so from the effects of disease. Over these parietes may be observed at times large veins filled with blood. We thought this venous engorgement 32 ANDRAL'S MEDICAL CLINIC. coincided pretty often with greater or less collection of limpid serum in the cavities of the ventricles. We never observed on the surface of the parietes of these cavities a fine injection similar to that which appears often on the pia mater around the brain. In more than one case we found, in the interior of the ventricles, either limpid serum in great quantity, or even a milky fluid, pus, membranous flocculi, like those of the peritoneum and pleurae ; and in those different cases where there existed within the ventricles so remarkable an alteration in the secretion, the membrane furnishing the morbid product did not itself present any appreciable alteration. These ventricular meningeal inflammations are very seldom found to exist separately ; they most frequently co-exist with meningitis of the base or convexity of the brain, and their symptoms are confounded with those produced by inflammation of the meninges of the other parts of the encephalon. The following cases may be interesting as rather uncommon instances of isolated ventricular meningitis. Case 17.—Sero-purulent effusion into the cerebral ventricles—Cystitis—Violent pain of head at the commencement, afterwards delirium, coma, tongue dry, retention of urine. A man, twenty-nine years old, a saltpetre maker, residing in Paris for the last eight months, generally enjoying good health, and regu- lar in his habits, awoke on the morning of the 21st December with a violent headache, feeling of lassitude, aching of the limbs and anorexia. This state of general uneasiness continued during the following days. He still continued to work till the 27th, when, feeling himself becoming feebler, he kept his bed. On the 31st he entered La Chariti, when he presented the following state :— Countenance pale, features drawn, and as if harassed, eyelids weighed down, air of stupor ; violent pain of head, particularly at the forehead, and extending sometimes to the rest of the head ; power of motion free ; muscular strength still considerable ; tongue red and dry ; some thirst; disgust for every kind of food ; slight pain in the epigastrium, constipation, pulse frequent and tolerably full, skin hot and dry, tumour in the hypogastric region formed by the bladder distended with urine.—(Blood-letting, blister to one leg, purgative enema.) On the following day the state of the patient the same ; no stool; the blood drawn presented a soft coagulum without buff. On the 3d, prostration, and air of stupor increased ; answers slow and difficult; constantly complains of headache ; para- lysis of bladder continued, which rendered the frequent introduction of the catheter necessary ; tongue moist; pressing on abdomen caused pain, which might depend on the distension of bladder; still constipation ; pulse yet frequent and full (sixteen leeches to neck twelve grains of Dover's powder, purgative enema). On the 4th no amendment: skin still dry ; tongue red, and again becoming dry; the enema had no effect; bladder very much distended (leeches again, and Dover's powder, lemonade, with a little wine added). DISEASES OF THE ENCEPHALIC MEMBRANES. 33 On the evening of the 5th became delirious, and on the following morning he uttered constant complaints ; he said he no longer had pain of head ; stupor more marked ; tongue red and dry ; one stool; urine very abundant, and still drawn off by the catheter. On the 7th, acute pain of head ; tongue quite dry ; pulse frequent, and of considerable strength ; skin dry and hot; thirst; delirium. On the 8th, profound coma; eyes closed ; mouth half open; answered no questions ; felt pain when abdomen was pressed ; when the skin of one of the extremities was pinched he drew it back, and face assumed an expression of pain. The two arms, when raised, fell back as inert masses ; respiration occasionally full and hurried ; then became slow, and the respiratory movements suc- ceeded each other at long intervals. The respiratory murmur not blended with any rattle, and its intensity not in proportion to the considerable raising of the thoracic parietes. Pulse one hundred and twenty, and the intervals of the pulsations unequal. Some subsultus in the tendons of the muscles of the forearm ; great quan- tity of urine. In the course of the day the intermissions of the respiration became more and more considerable ; at last it stopped altogether, and the patient expired. Post mortem.—Several veins in the subarachnoid cellular tissue of the convexity of the hemispheres gorged with blood. On making an incision into the upper wall of each lateral ventricle, an immense quantity of milky serum flowed out, in which some albuminous flocculi floated. On slightly touching the internal wall of each of the ventricles, from the ancyroid cavity to the anterior extremity of their inferior portion, the cerebral substance was found very soft for the space of one or two lines, and seemed as it were diffluent under the finger. Thorax.—Nothing particular. •Abdomen.—A great quantity of liquids distended the stomach. We observed on its inner surface two red spots, one the size of a five-sous piece, and the other that of a twenty-sous piece. In the large intestine, veins were seen in considerable numbers in the mucous membrane of the caecum. The mucous membrane of the bladder exhibited a bright red injection in its entire extent; and in several parts it was covered with a purulent exudation. Remarks.—This case resembled in many points, with respect to the symptoms, certain cases of typhoid fevers, to be recorded in another portion of this work. The tongue, which we found in its natural state in the cases preceding this, here presented that redness and dryness so common in dothinenteritis ; the countenance also presented that air of stupor so characteristic of exanthematous inflam- mation of the small intestine. There was no other cerebral symp- tom, properly speaking, except the delirium followed by profound coma, and even those two symptoms appeared only during the last two days. Pulse was constantly frequent, and the skin presented that dryness so often accompanying acute inflammation of the in- testinal follicles, to which part, in fact, one would for many reasons 5* 34 ANDRAL'S MEDICAL CLINIC. be inclined to refer the seat of the disease, and the cause of the con- tinued fever. Yet the post mortem disproved this ; what we found being a sero-purulent effusion into the lateral ventricles, with a super- ficial softening of the cerebral substance of a portion of their parietes. We also found remarkable lesions in the bladder, its mucous membrane being every where red, and a purulent layer covering it. Was then the retention of the urine in this case connected with cystitis ? or was the latter the result of the repeated introduction of the catheter ? If we now recur to the commencement of the disease, we shall find that it began with headache, a symptom, the frequent, though not necessary existence of which we have also observed in meningitis of the base, as well as in that of the convexity of the cerebral hemi- spheres. This having been the first symptom, we had certainly some reason for suspecting the brain or its membranes to be the part affected, yet we could not have been certain of it, particularly when we recollect pain of head similar to this, to have ushered in and accompanied as the leading symptom, different cases of dothinente- ritis. Shall we take into account, in order to establish our diagnosis the remarkable state of the respiration towards the close ! Frank, in fact has given, as one of the characteristic signs of encephalitis, those long intermissions of the respiration : in this disease, he says the patient respires deeply, and at long intervals ; Spiratio magna ex longis intervallis ducitur. But the same state of the respira- tion has been found in several cases of dothinenteritis, without any appreciable lesion of the brain after death. Case 18.—Sero-purulent effusion into the lateral ventricles—Granular appearance of the membrane lining their parietes—Alternation of delirium and coma : of stupor and violent agitation; of abolition of muscular contractions, of strong tetanic twitches— Pulse occasionally rare and frequent. A lapidary, twenty-one years of age, was admitted into La Chariti on the 20th of April 1820. What particularly struck us then, was his air of dejection ; he kept his head under the bed-clothes, and refused to answer questions ; he merely told us that, for several days he had, over the entire abdomen, pains which were not in- creased by pressure, and that for a considerable time he had no stool ; pulse not frequent. The nature of the abdominal pains, the consti- pation and apyrexia, together with the circumstance of his being a lapidary, caused us to suspect lead colic. The ordinary treatment of the hospital for this affection was accordingly adopted. On the 21st, skin hot; pulse frequent; the treatment of the pre- ceding day discontinued. Diluent drinks prescribed. From the 21st to 26th, the fever continued ; the air of sadness still remains ; slight abdominal pains ; constipation still ; tongue natural (drinks continued ; purgative clyster ; linseed cataplasms over the abdomen). On the 26th, patient lay on his back, his look being fixed ; the two pupils a little contracted, the right less than the left; head somewhat turned back. He refused to answer questions, and talked DISEASES OF THE ENCEPHALIC MEMBRANES. 35 incoherently ; several times in the night he attempted to escape out of bed, so that restraint became necessary. Tongue natural; pulse frequent (two blisters to the legs). On the morning of 27th, profound stupor ; patient performs no motion whatever ; abdominal pressure gives no pain ; pulse lost its frequency ; heat of skin no longer raised ; constipation still conti- nues—(eight leeches behind each ear ; two blisters to the thighs ; mineral lemonade). On the 28th, comatose state quite gone ; he puts out his tongue when asked, but gives no other signs of intellect; utters not a word ; pupils a little dilated ; tongue natural; no stool ; apyrexia (purgative enema, &c). 29th, No change ; but on the 30th agitation and delirium, as on the 26th ; constantly rubbing his hands together ; belly tympanitic ; pulse not frequent; tongue moist and pale (twenty leeches to neck ; twelve grains of calomel). 1st May, delirium continues ; retroversion of the head ; carpholo- gy; pupils dilated ; pulse very frequent; abdomen tympanitic (twelve grains of calomel ; frictions to the abdomen, with linim. ammon. camphor., and aromatic fomentations to the same part). 2d May, delirium continues, as also the carphology ; continual tossing of the head alternately from right to left, and vice versa ; moaning ; sudden shocks of the trunk and limbs, like those of tetanus ; carotids beat strongly ; the heart raises the parietes of the thorax ; tympanitis considerable. Death at eight o'clock at night, after discharging a considerable quantity of blood from the nose and mouth.. Post mortem.—On a level with the centrum ovale of Vieussens, on each side of the corpus callosum, we perceive a manifest fluc- tuation ; an incision made into the lateral parts gave exit to a con- siderable quantity of liquid, like whey not clarified, in the middle of which albuminous shreds are seen to float. From the surface of the parietes of each ventricle, a very thin membrane is detached, which is traversed by very minute vessels curiously injected. On some points of the free surface of this membrane, small greyish bodies exist, the size of a pin's head, like the rudiments of false mem- branes, which, under the form of granulations, are sometimes scattered over the peritoneum. Thorax.—The pleura costalis and pulmonalis adhere by well or- ganised cellular tissue. The lung of this side contained a great number of tubercles, principally miliary, some were larger, and softened. The bronchi of this lung were very red, and the bron- chial ganglia hard and black. The left lung also adhered to the pleura, but contained not a trace of tubercle. The two serous folds of the pericardium were internally united to each other by a false membrane several lines in thickness. Abdomen.—The anterior wall of this cavity projected considera- bly before the throax ; when struck it sounded like a drum. The intestines were enormously distended with gas ; stomach contained 36 ANDRAL'S MEDICAL CLINIC. a great quantity of mucus, and the small intestine a great quantity of bile. In the caecum and colon, ascending as well as transverse, the mucous membrane was very much injected. The left lumbar colon, filled with very hard faecal matter, was white on its internal surface, as was the sigmoid flexure and the rectum ; above this last intestine was a very marked circular contraction. The gases and fasces accumulated in the colon could with difficulty get through it ; rectum empty. Remarks.—In this patient the nervous symptoms were much more marked and varied than in the preceding. In both, the cere- bral lesion was of the same nature, and had the same seat. In the latter case, as in the former, the lesion discoverable by anatomy ex- isted only in the lateral ventricles. With this inflammation of the ventricular membrane coincided different symptoms, some of which are generally regarded as characterising meningitis of the convexity of the hemispheres, and others more especially connected with meningitis of the base ; thus on the one hand there was delirium and frequent tossing, on the other a state of coma. We often see these two orders of symptoms replace each other, and at the same time there are observed very remarkable disturbances in the muscu- lar contraction, characterised by shocks of the trunk and limbs like those of tetanus, and a forcible reversion of the head. If we refer to the period when we first saw the case, we shall again find some phenomena worthy of remark, connected with the nervous system. The profound sadness of the patient then, that air of dejection, and disposition to conceal his head under the bed clothes, as if to avoid our look and questions, his reluctance to answer, &c, were certain indications of a commencing cerebral affection. This state "of the patient prevented us, unfortunately, from procuring any information as to what he had suffered before he came to hospital—as, for in- stance, whether he had had pain of head. The tongue was con- stantly natural, not so in the preceding case ; and yet the primae viae were here effected ; for at different times, and especially on en- tering the hospital, he complained of acute pain in the abdomen, and had most obstinate constipation. Had he the beginning of lead colic ? We must not lose sight of the bright red appearance found in a great portion of the large intestine, and the accumulation of faeces in the sigmoid flexure, which a circular contraction of the com- mencement of the rectum prevented from passing into the latter intestine. This contraction depended on no organic lesion ; it ap- peared to be the result of a spasmodic affection of the muscular coat. Case 19—Serous effusion into the cerebral ventricles—Pain of head at the commence- ment—Subsequently coma—Acceleration of the pulse some hours only before death. A mason twenty-three years of age, had been complaining for several days of violent pain of head, when he entered the hospital. Tongue white ; pulse not frequent ; no other ailment than the head- ache. Two grains of tartar emetic were given him He vomited twice very copiously, and had two stools. The following day the state of the patient underwent a remarkable change. His intel- DISEASES OF THE ENCEPHALIC MEMBRANES. 37 lect very much diminished ; he answered questions slowly and with difficulty. Still complained of the headache ; pulse and tongue natural. (Twelve leeches behind each ear.) On the 17th. Great stupor. On being very much solicited, he opened his eyes slowly, and looked around him with the most va- cant stare. On being asked how he found himself, he answered, that he was doing very well. Pupils did not contract on the approach of a very strong light ; they were not much dilated, the right a little less so than the left. State of pulse and skin natural. (Six leeches to each mastoid process ; a pint of whey, with the addition of a grain of tartar emetic, and four drachms of sulphate of soda ; two blisters to the thighs ; frictions with linim. volat. cantharid. to the extrem- ities.) 18th. Stupor continues ; utters some unmeaning words ; puts out his tongue when asked ; pupils more dilated than on the preceding day, and eqally so ; pulse has acquired some frequency : tongue dry ; bladder very much distended—(a pint of whey, with a grain of tartar emetic, and an ounce of sulphate of soda ; frictions with linim. ammon). During the day the coma increased, and he died during the night. Post mortem.—The two lateral ventricles were found to be very much distended with limpid serum; some was also found in the third ventricle. Nothing remarkable was observed in the other cavities. Remarks.—The symptoms here did not differ much from those in the seventeenth and eighteenth cases, in which pus was found to fill the ventricles. There was no febrile excitement at all in the course of the disease, and it was only a few hours before death that the pulse became accelerated. Case 20.—Copious serous effusion into the lateral ventricles—Destruction of the for- nix and septum lucidum—Symptoms of apoplexy. A man, fifty years of age, entered La Chariti with considerable anasarca and ascites ; no local sign of organic disease of the heart; respiration free ; states that he never felt any pain in the right hy- pochondrium ; the dropsical effusion took place three months previ- ously, but we could not learn from him where it commenced ; digestion well performed ; no new symptom presented for the fifteen days following, One morning, on approaching his bed, we found him in a state of apoplexy, totally deprived of consciousness. We were told that since the evening before he had not spoken ; face pale ; eyes appeared deprived of sight; both pupils sensibly dilated ; the extremities when raised fall as inert masses ; total insensibility ; pulse not frequent ; respiration hurried and stertorous ; tracheal rattle very loud. He died some hours after the visit. Post mortem.—Considerable serous infiltration of the upper and lower extemities. Cranium.—A small quantity of limpid serum infiltrates the sub- arachnoid cellular tissue of the convexity of the brain. The two lateral ventricles were confounded with the third into one enormous 38 ANDRAL'S MEDICAL CLINIC. cavity, from which there flowed two glasses full, at least, of serum clear as spring water. In the place of the septum lucidum and fornix, there was nothing but small fragments of a white pulp float- ing amidst the serum. Thorax.—Lungs very much engorged ; in other respects sound. In the heart, which was natural in every respect, and in the rest of the arterial system, there was found but a very small quantity of blood, remarkably liquid. Some liquid blood, and that in small quantity, was all that was found in the veins. Abdomen.—The peritoneum contained several pints of limpid serum. The liver, which was of the ordinary size, was remarka- ble for its great hardness—as also the spleen. Remarks.—Here again we have a considerable effusion of serum into the ventricles, together with a breaking down of the central white parts of the brain. We are disposed to consider the destruc- tion of the septum lucidum and the fornix as the mechanical result of the pressure made on them by the fluid in each ventricle. In the two cases preceding we have seen, notwithstanding the identity of the lesions found after death, that the symptoms were far from being similar. Here again we have the same lesions, and the symptoms were those of apoplexy, that species of it usually called serous apoplexy. Dropsy, of which the cause was obscure, was the only disease the patient laboured under up to the apoplectic attack; and, to account for this dropsy, we found no other lesion, except the morbid state of the liver. There existed'already, then, in this indi- vidual, a disposition of long standing to serous effusions ; when suddenly, no doubt, the serous membrane, lining the cerebral ven- tricles, exhaled a large quantity of serum, which caused all the symp- toms of real apoplexy. Thus we have sometimes seen in dropsical patients great dyspnoea suddenly supervene, and death follow after some hours the constantly increasing difficulty of respiration. It was accounted for by a serous effusion which took place all at once into both pleurae. In the present case the anasarca and ascites did not diminish when the effusion into the cerebral ventricles took place. In another individual, whose history shall be given elsewhere, both the anasarca and ascites were considerably diminished before the appearance of the apoplectic symptoms, which, as in the present case, were produced by a sudden effusion of serum into the cerebral ventricles.* * A case somewhat similar occurred in Dublin, about three years since, under my own care. It was that of a man of very intemperate habits, whose liver was considerably enlarged; he had ascites and anasarca, and was treated in the usual way, without any amendment. One morning when he awoke, he found the size of the abdomen very much diminished, and the swelling of the lower extremities quite gone. He arose from bed at twelve o'clock in the day, sat a few hours at the fire, became drowsy, threw himself on the bed, and when his wife went to call him, at about four o'clock in the evening, she found him dead. The ventri- cles of the brain were found to be enormously distended with limpid serum.__T. DISEASES OF THE ENCEPHALIC MEMBRANES. Case 21.—Considerable serous effusion into the lateral ventricles, with destruction of the septum lucidum and of part of the fornix—Ossification of the great falx Cerebri —Symptoms of apoplexy. A man, seventy-two years of age, entered the La Charite" during the month of December, 1821. He had been for a long time labouring under pulmonary catarrh ; for the last two months he kept his bed, being very much debilitated. When we saw him, he had some fever; tongue dry and brownish red; a little cough in very distress- ing kinks, accompanied with the expectoration of puriform mucus; intellect sound. He was ordered pectoral drinks, which he con- tinued to use for fifteen days, when suddenly he lost all conscious- ness ; his eyes closed; the four extremities lost the faculties of sensation and motion ; sensibility gone; on raising the eyelids we might touch the conjunctiva without his feeling pain; the pupils were dilated and immoveable; the pulse retained some strength and considerable hardness, but had lost its frequency; the skin was covered with a copious sweat; each inspiratory movement was ac- companied with a loud tracheal rale. Death took place the follow- ing night. Post mortem—Cranium.—More than an ordinary glass full of water filled both lateral ventricles; no trace of the septum; in place of the middle part of the fornix, we found a white pulp, which was raised with the scalpel from the upper surface of the choroid plexus. The great falx cerebri ossified. Thorax.—Considerable infarction of the lungs. On cutting into them, a considerable quantity of frothy, colourless serum flowed from their tissue. Slight hypertrophy of the parietes of the left ventricle ; numerous incrustations on the inner membrane of the aorta. Abdomen.—A viscid mucus covers in considerable quantity the inner surface of the stomach; beneath it a bright injection of its mucous membrane towards the great curvature, as also of the small intestine. Remarks.—This is a well-marked case of what is called serous apoplexy coming on in an old man, exhausted by chronic irritation of the gastro-pulmonary mucous membrane. In this, as in the pre- ceding case, the patient lived but a few hours after the first symp- toms of apoplexy, during which the pulse retained its hardness, but became very slow; the slowness depending on the serous effusion into the ventricles of the brain, and the hardness of the pulse on the commencing hypertrophy of the parietes of the left ventricle. Case 22.—Sanguineous congestions in the brain, terminating in serous effusion into the lateral ventricles. A woman, fifty-one years old, of a sanguine temperament and strong constitution, ceased to menstruate about her forty-ninth year; du- ring the six months following she was subject to a numbness in the right arrh. In her fifty-first year she suddenly lost consciousness, fell, and retained, when she came to herself, some difficulty in her 40 ANDRAL'S MEDICAL CLINIC. speech, with some falling of the commissure of the lips and tongue on the right side, considerable diminution of motion and sensation on this side, nausea and bilious vomiting. Under proper treatment this state disappeared at the end of four weeks. After this the pa- tient returned to a perfect state of health, when, towards the middle of March, 1819, she again began to feel a little weakness in the right arm ; slight pains of head in the frontal region soon supervened, and, on the 26th of April, without any obvious cause, there came on in the night, during sleep, a new attack, more violent than the former, and of the same side; total loss of speech; considerable di- minution of sensation, but particularly of motion, in the extremities of the right side ; features not altered; tongue fell a little on the right side. This new attack disappeared, however, more promptly than the preceding, and at the end of three days, the patient having entered the hospital, presented the following state:—She had slept well the previous night; some weight of head; tongue unsteady when she puts it out; some numbness and weakness on the right side of the body; speaks distinctly ; pulse full, strong, and slow ; habitual constipation (lemonade with cream of tartar ; fifteen leeches to each foot; warm pediluvium ; purgative enema). In the morn- ing she took some soup, and was seized with vomiting in the course of the day, when she threw up some bile. The vomiting brought on a new attack, followed by an increase of the hemiplegia on the right side and greater embarrassment of speech. She was bled to ten ounces. New attacks of a slight nature appeared in the night, upon which sinapisms were applied to the feet: after this the faeces passed involuntarily. On the 30th, hemiplegia more developed ; articulation nearly impossible ; pulse less full, less hard, and more accelerated ; paralysis of the bladder (lemonade with one ounce of soluble tartar ; bleeding from the jugular vein ; purgative enemata; introduction of the catheter). Immediately after the bleeding (ten ounces) a new attack, followed by total loss of speech, and of mo- tion in the right extremities ; frothing at the mouth ; dilatation of the pupils ; countenance quite vacant. On the following morning these symptoms were all aggravated ; trismus also supervened, which prevented her from drinking, and constant drowsiness. On 1st of May, pupils immoveable, blindness, trismus, frothing at the mouth at each expiration ; contractility abolished on the right side, almost none on the left; a little sensibility on both sides rather more on the left; pulse full, hard, irregular for the number of pul- sations (twenty leeches to the neck; blister to legs ; purgative ene- mata). She died a little after the visit. Post mortem—Cranium.—The lateral ventricles contained nearly four ounces of limpid serum ; no leison in the thoracic or abdominal viscera. Remarks.—The apoplectic attacks in this case seem to have been produced by simple sanguineous congestions in the brain. It would appear that here the hemiplegia was the result of a sanguineous con- gestion greater in one hemisphere than in the other, whereby this DISEASES OF THE ENCEPHALIC MEMBRANES. 41 hemisphere lost its influence over the muscular contractility, even when the congestion ceased to exist. The first time the hemiplegia was preceded by a total loss of consciousness ; the second time it was gradual, and not announced by any symptom of apoplectic attack. The more alarming symptoms observed for the last two days were the result of a serous effusion into the ventricles, of which the habitual sanguineous congestions had been probably a predispos- ing cause. We should not forget to notice here the influence of the vomiting on increasing the hemiplegia. CHAPTER IV. CASES WHEREIN THE ENTIRE OF THE MENINGES WERE INVOLVED. Case 23.—A man, fifty years of age, naturally of a strong consti- tution, having been very unsuccessful in his commercial speculations, came to Paris, where, after residing for some time, he became affected with general debility, which went on daily increasing. At last he entered La Chariti on the 11th November, 1821. During the first two or three days he scarcely appeared ill in any way; but was plunged into a profound melancholy. On the 15th, he complained of total aversion to food ; his tongue was covered with a thick yel- low coat ; abdomen free from pain ; no fever. During the day he took twelve grains of ipecac, and vomited abundantly. On the following day he seemed better. On the 17th, however, the pulse had become frequent; tongue showed a tendency to become dry ; he vomited his drinks ; his bladder, distended with urine, formed a tumour above the pubis ; he explained his state perfectly ; he was still more sad and taciturn than usual (the urine was drawn off; lin- seed clysters). 18th. Same state of bladder; countenance exhibits great stupor ; still the intellectual and sensorial faculties unimpaired ; patient complains only of great debility ; tongue moist and foul ; no stool ; pulse scarcely frequent; skin not hot—(enema of marsh- mallow with a scruple of camphor ; frictions on the extremities with linim. volat. cantharid.). 19th. In the same state. 20th. Pros- tration greater ; he lies on his back quite motionless, with his eyes turned up and fixed ; he appeared indifferent to every thing passing around him ; answers questions precisely, but slowly; pulse frequent; skin hot; tongue still moist (six leeches to the anus ; camphor enema, lemonade). On the 21st, for the first time, he com- plained of headache, without being able to point out its precise seat; though he answered questions, still his mind was disturbed at inter- vals ; his eyes were constantly directed towards the roof of the bed, except when he was spoken to ; tongue, which was very yellow, again showed a tendency to become dry ; abdomen was tympanitic, Sept. 1838.—M 6 42 ANDRAL'S MEDICAL CLINIC. and since the preceding day the faeces passed involuntarily—they were liquid ; pulse very frequent and compressible (four leeches behind each ear; fomentation with camphorated oil of camom. to the abdomen ; sinapisms to the lower extremities ; infus. quinquin. &c). In the course of the day the faeces passed involuntarily twice ; raved all the night. On the 22d, stupor more marked ; eyes, which were directed towards the roof of the bed, were occasionally closed ; mouth half open ; no'answer could be elicited from him ; tongue very dry, and a dark yellow ; abdomen again soft; on pressing it strongly the respiration was very much accelerated ; pulse ninety- eight, very small, and very irregular ; the skin covered with an abundant sweat. On the 23d, eyes dull, features quite altered ; pulse one hundred, and thready ; skin still hot and moist ; passed no urine for the last twenty-four hours. He died in the course of the day. Post mortem forty-six hours after death—Cranium.—Consid- erable injection of the membranes over the entire convexity of the cerebral hemispheres. Towards the anterior extremity of the inner surface of these hemispheres, the arachnoid was raised on both sides by a purulent layer, which was displaced, but not removed, by passing the back of a scalpel over this membrane. The pia mater was infiltrated with pus through the entire extent of the fissure of Sylvius on the right side ; a layer of this same liquid was found on the upper surface of the two lobes of the cerebellum. The upper wall of each of the lateral ventricles was very much raised, and pre- sented an evident fluctuation. Each lateral ventricle contains, in fact, a greyish liquid, in the midst of which numerous flocculi float: these also accumulated in the lower part of the ventricles, form a thick layer which covers the cornu ammonis on each side. Some whitish laminae were also found on the lower surface of the cerebral hemispheres. Thus surrounded on all sides by a layer of pus, the cerebral substance underwent no appreciable alteration, not being even injected. Thorax.—Anterior part of the two lungs empty of blood, whilst the posterior portion was gorged with it. The left cavities of the heart empty; the right cavities contain a small quantity of liquid black blood. In the thoracic aorta is a fibrinous clot divested of colouring matter. The vena cava in the abdomen full of liquid black blood. Abdomen.—The convolutions of the small intestine were dis- tended with gases; the transverse colon also contains a great quantity of them. The stomach, which was covered by the colon and the liver, was distended with a mixture of gas and liquid in its splenic portion, whilst it was contracted in its pyloric extremity; the inner surface of the stomach of a brownish grey, through the whole extent of the great curvature; the duodenum, and two upper thirds of the small intestine, contained a great quantity of a yellow, viscid liquid which colours very deeply the internal surface, and particularly the valvulae. This portion of intestine, when washed, presents no DISEASES OF THE ENCEPHALIC MEMBRANES. appearance of injection. The lower third of the small intestine contains a greenish matter more liquid, but not viscid; its inner surface is pale, except in three places, where there is observed a deep red colour, the seat of which is in the mucous membrane. Here we found three patches forming a slight projection above the level of the rest of the mucous membrane, each of them being about the size of a five-franc piece. For the extent of four fingers above the ileo- coecal valve, the mucous membrane was uniformly injected. The large intestine contains a greenish liquid; its inner surface presents through its entire extent a slight injection of the mucous membrane. The liver is remarkably large ; it extends into the left hypochon- drium, and is interposed between the abdominal parietes and the spleen, to which it is united by cellular adhesions ; its tissue is, in some degree, gorged with blood ; it presents a red ground, traversed by numerous white lines. Spleen large and very soft. The bladder, which is contracted, contains not a drop of urine, and its mucous membrane is injected, and on one part of it there is a small eschar. Remarks.—The group of symptoms presented by this individual bear much closer resemblance to those appertaining to a severe dothinenteritis, than to those connected with acute meningitis. On the dead body we found the latter very much developed ; but there were also indisputable, though very slight traces of a morbid state of the intestinal follicles. It was certainly on their inflammatory engorgement that those three red marks depended, which projected above the level of the intestinal surface, the existence of which we found not far from the caecum. We may further observe, that this person had but recently arrived in Paris ; on the other hand, he had passed the age at which persons are usually attacked with dothinenteritis. The moral causes which had been operating on him, seemed more particularly to have disposed him to a cerebral affection. In subsequent parts of this work, we shall meet more than one case in every respect analogous to this with respect to the symptoms, in which, however, he nervous centres presented no ap- preciable lesion after death. A question may be raised, whether this meningitis, so remarkable for its extent and for the quantity of pus effused into the pia mater and the ventricles, was not an additional phenomenon, or a complication, and whether it might not have been absent, and the disease still have retained the same form, observed the same progress, and been attended with the same severity ? Se- veral facts, which shall be stated in another place, warrant us in thinking that the question may be answered in the affirmative. Case 24.—Thickening of the membranes on the convexity of the hemispheres, and at their base—Tubercles in these membranes, and in the cerebral substance itself, which is red and softened around them—Tubercular diathesis—Symptoms of apo- plexy at the commencement and termination of the disease. A man, thirty-three years old, had experienced, five days before entering La Charite", all the symptoms of an apoplectic attack ; the loss of consciousness continued for twenty hours. On the following 44 ANDRAL'S MEDICAL CLINIC. days he continued paralysed on the right side ; then delirium super- vened, and the patient was admitted into the hospital after having been bled three times from the arm. He then presented the follow- ing state :—Face pale; delirium , equal facility in moving the extre- mities of the right and left side ; pulse and tongue natural. On the day after, Feb. 23, the eighth day of the disease, the delirium still continues; air of restlessness ; sinking of the features ; pulse hard, still not frequent; tongue white and moist (sixteen leeches to neck). On the 26th, intellect scarcely disturbed ; answers slow, but accurate (eight leeches to neck). 27th, Delirium returned ; pulse now for the first time has become frequent. 2Sth, Eight leeches across each jugular vein. On the 2d and 3d of March, delirium complete, with fever (twelve leeches to the neck each day). This state continued with very little change for twelve days following, during which leeches were frequently applied to the neck, when, on the 16th, the patient suddenly fell into a state of the most profound coma ; at the time of the visit he seemed like a man who has just' had a violent attack of apoplexy. He expired some hours after. Post mortem—Cranium.—The arachnoid lining the inner sur- face of the dura mater readily separates from it; the membrane covering the entire convexity of the cerebral hemispheres is opaque, very white, and several lines thick ; the pia mater is the principal seat of this thickening. On the lower surface of the left hemisphere, towards its middle part, we observe in the meninges opaque portions similar in appearance to the meninges of the convexity ; but here other peculiarities are also observed ; these opaque portions princi- pally exist in the intervals between three or four circumvolutions ; the anfractuosity, which should separate them had disappeared, and these circumvolutions closely adhere to one another. On the infil- trated and thickened pia mater which unites them, there are obser- ved small whitish miliary granulations, of a tubercular appearance, set in order like so many beads. In the grey substance of the ad- hering convolutions, there appear several of these granulations ; around each of them the cerebral substance is very much injected and softened for the extent of some lines. Thorax.—Similar granulations are also found in great, quantity in the substance of the two lungs, and some also in the pleurae. Abdomen.—The inner surface of the stomach white, and slightly injected towards the great curvature ; a tumour, the size of a nut projects on the interior of the stomach in the same direction ; when cut into it was found to consist of a sac, the raised mucous mem- brane forming its parietes, and the cavity being filled with softened tubercular matter ; this sac communicated with a large tubercular lymphatic ganglion attached to the great curvature of the stomach. The upper portion of the small intestine a little injected ; some tubercles were found between the peritoneum and muscular coat of the intestine ; the mesenteric ganglia very large. In front of the vertebral column there was found an enormous tubercular mass consisting of the ganglia which exist ordinarily around the recepta- DISEASES OF THE ENCEPHALIC MEMBRANES. 45 culum chyli ; the same tubercular ganglia are found in the throax all along the thoracic duct ; a large tubercular mass exists also in the fissure of the spleen ; other tubercular masses fill up the different furrows of the liver ; in the interior of the liver we observed seve- ral small round bodies, white, and of considerable hardness, present- ing at their centre a yellow point; similar bodies are found in the central part of the kidneys, but without the yellow point in their centre ; three or four of these bodies were also found in the pan- creas. Remarks.—This disease, after commencing with all the symp- toms of an apoplectic attack, entirely changed its form. The apo- plectic phenomena disappeared altogether ; not a trace even of the paralysis which followed the loss of consciousness remained. But another scene commenced ; and we behold most of those symptoms develop themselves belonging to the disease designated by Huxham under the name of slow nervous fever. On the part of the nervous centres, we detect no other functional disturbance, except that of the intellect, and even that is not permanent. The disease, after lasting twenty-nine days, returned to its original form, and the patient was carried off in a few hours with the symptoms of apoplexy. The post mortem examination presented very remarkable lesions. The state of the meninges of the convexity of the cerebral hemispheres, accounts for the disturbance of the intellect, but it does not explain the alternate increase and decrease of the delirium. The lesions at the base were of the same nature as those on the convexity of the brain. We must not lose sight of those red softenings scattered through the grey substance of some of the circumvolutions, and of those precisely whose investing membranes were also diseased.— Was this part of the brain the seat of the apoplexy, in which the dis- ease terminated ? This appears so much the more probable, as the paralysis was on the right side, and it was at the base of the middle part of the left hemisphere that these softened points existed. But why did the symptoms of apoplexy disappear ? Why did the para- lysis cease? No doubt, because the cerebral lesion, being at first but slight, disappeared of itself. But by reason of the disposition to tubercular secretion existing in this individual, tubercles took the place of the blood that had been effused into the cerebral substance, whilst they were also deposited in the cerebral membranes. At a later period, no doubt a new inflammatory process took place around each cerebral tubercle, and thence perhaps the new attack of apo- plexy which carried off the patient. Case 25.—Pain of head of very long standing—Suddenly delirium; then coma— Symptoms of apoplexy and death—Purulent effusion on the convexity of the cerebral hemispheres, at the base of the brain and into the ventricles—Old cellular adhesions of the two folds of the arachnoid—ossification of the retina. A shoe-maker, thirty-eight years of age, of strong constitution, de- prived of the left eye from his infancy, was troubled all his life with pains of the head, the seat of which he usually referred to the 6* 46 ANDRAL'S MEDICAL CLINIC. left side of the cranium ; fourteen months previous he received some violent blows on the head in a fight, since which occurrence his headache became more frequent and more severe ; he often feels a dizziness. On the 13th June, after his work, he complained of general illness, and of a more violent headache than ever over the left side of the cranium ; during the night he became very feverish. On the 15th he was bled. On the 16th, some delirium at intervals. On the 17th, constant stupor (a blister was applied to nape of neck). On the 18th he entered La Charite" and on the 19th (the seventh day of his illness) he presented the following state : face pale ; eyes shut ; appearance of tranquil sleep, from which it is almost impossible to arouse him ; when he does open his eyes he looks around him with a stupid air, utters not a word ; power of motion perfect, but sensi- bility diminished ; passes his faeces under him—(one ounce of sulphate of soda, sinapisms). On the 20th, no change. 21st, pulse accelerated; heat of skin very much raised; still comatose; sub- sultus in both arms ; bled from the arm ; blood covered with a thick coat. On the 22d new symptoms were observed ; left eyelid remained depressed over the eye; the right eye, on the contrary, wide open, fixed and dull; pupil of this side dilated and immovable ; at each expiratory movement the left cheek was pushed out, announc- ing commencing paralysis of the muscles of this side of the face. The right arm, when raised, fell again as an inert mass ; subsultus in the two fore-arms. Pinching the skin gives not the least pain ; respi- ration stertorous ; pulse frequent and strong ; skin covered with sweat. In the course of the day the coma became more and more profound, and the respiration more difficult, and at five in the even- ing he died. Post mortem—Cranium.—Cellular adhesions, similar to those often uniting the pleura, extended from the arachnoid covering the hemispheres, to that lining the dura mater. The pia mater, in the upper surface, very much injected. The lateral ventricles were distended by a great quantity of a whey-like liquid. The menin- ges of the brain were generally injected. A thick purulent layer, which was seated in the pia mater covering the left cerebral pedun- cle, the left portion of the medulla oblongata, and extended, like a sheath, over the nerves arising from this part. Nothing remarkable in the thorax or abdomen. Examination of the left eye.—The transparent cornea was thick and opaque ; the opening of the iris was completely obliterated by a white membrane several lines thick, the edge of which adhered to the circumference of the iris ; no longer any trace of the crystal- line lens. The vitreous humour had a milky appearance. Not a trace of retina, but in its place we found a small bony shell, having a small hole in the centre; its concave surface was applied to the corpus vitreum ; no vestige of the ramifications of the optic nerve was discovered on it. The left optic nerve was smaller than the other, and of a grey colour, from the sella turcica to its entrance into the eye; it terminated at the central hole in the bony shell DISEASES OF THE ENCEPHALIC MEMBRANES. above described, by a bulb apparently fibrous, and similar to the swelling found in the extremities of nerves in amputated limbs. From their origin to their crossing the two optic nerves were per- fectly similar. Remarks.—In this individual two species of alteration were found within the cranium, and all two had their share in the production of the symptoms. The one of these alterations was of long stand- ing, namely, the cellular adhesions uniting the two layers of the arachnoid. It is very probable, that on these depended the head- aches which so long annoyed the patient. Anatomy, however, does not inform us why the pain of the head was more severe on the left than on the right. The exasperation of this pain of head, marked the commencement of the acute disease, for which he entered the hospital, and which was sufficiently accounted for by the purulent effusions found on the upper surface of the brain, its base, and in the ventricles. We may observe, that the purulent layer of the base was confined to one of the cerebral peduncles, the left, and also to the left pons varolii and medulla oblongata. We may also observe the purulent sheath, surrounding the nerves, arising from the left side of this part of the brain. Is it in consequence of these anatomi- cal circumstances that, towards the termination of the disease, the left eyelid, and cheek of the same side, became paralysed, at the same time that all motion seemed extinct in the right arm ? Violent pain of head, fever, general illness, were all that we observed during the first days of the disease. Some delirium set in on the 4th, which, on the 5th, was succeeded by a state of coma, which went on increasing to the 10th day, when he died, a little after symptoms of paralysis appeared. To explain this succession of phenomena, shall we say that the meninges of the convexity of the hemispheres were, at first, irritated, and that it was then the delirium appeared, and that the coma which succeeded this delirium, announced the exten- sion of the meningitis towards the base of the brain and into the ventricles ? We have already seen, however, that it is not always possible to determine from the prevailing symptoms, what portion of the meninges is especially affected. The circulation did not pre- sent that slowness here which it did in other cases. The pulse, which was natural on coming to the hospital, became frequent and febrile, in proportion as the state of coma became more and more developed. We have observed the contrary in the other cases. 48 ANDRAL'S MEDICAL CLINIC. CHAPTER V. DISEASES OF THE MEMBRANES OF THE SPINAL CORD. Case 26.—Spinal arachnitis—Arachnitis of the base and convexity of the brain- Milky serum in the ventricles.* A woman, twenty-eight years of age, the mother of four children, had been very much distressed by certain insulting proposals made to her; her menses were suddenly suppressed in the midst of their course, and she was instantly seized with violent shivering, which lasted twenty-four hours. The next day, great heat of skin ; burn- ing thirst;' a sense of squeezing at the throat; bolus hystericus very marked. On the third day, bilious vomiting ; she vomited also *The following very interesting cases, which serve to illustrate the principal circumstances connected with disease of the upper cervical vertebrae, are con- densed from Dr. Bright's Medical Reports, vol. ii. part 1, page 415. They were communicated to him by Mr. Key :— Case 1.—Slight Paralysis from disease of the Cervical Vertebrae. A young lady, aged thirteen, had been for about twelve months troubled with pain in the neck, which at first was considered as the effect of a cold. This not going off, was treated by her medical attendant as a glandular affection. This pain continued to increase, until at last she could not rise from the horizontal position without great pain, being also obliged to support her head by placing her hands on each side. When Mr. Key first saw her, she was emaciated, and her counte- nance betrayed great suffering. On examining her neck there appeared a general fulness, which gave her pain on pressure; she had the power of slightly moving the head backwards and forwards, but the lateral movement was accompanied with so much pain that she could not be prevailed on to attempt it. The case seemed evidently an affection of the two upper cervical vertebrae. After some time a tumour was perceived at the back of the pharynx, which, on puncture, yielded about three ounces of pus, and which Mr. E. concluded had communica- tion with the diseased spine. This gave some relief; but her emaciation and suffering increased. About a fortnight before her death, vomiting came on whenever she took food, which was allayed by a blister applied in the course of the par vagum in the neck; she had convulsive twitchings of the upper extremi- ties, and a slight paralytic affection of one arm. She sunk gradually. The second case was that of a young man, aged twenty-three years, who seemed to labour under an affection similar to the last, with a strong tendency to phthisis. Connected with the disease there appeared a tumour in the neck on the right side, just behind the angle of the jaw, which projected into the pharynx; on puncturing this, a quantity of pus escaped, which gave great relief to his breathing and to his pain. The tumour formed again in four days after, and burst, and it does not appear that it gathered afterwards; the external tumour disap- peared. He complained of some soreness low down in the oesophagus in swal- lowing; there was a slight lateral protrusion of the second vertebra. The third case was that of a young man, eighteen years old, who complained of great stiffness with swelling at the back of the neck, which he had been complaining of for six months, and which was considered rheumatic. He could not rise from the recumbent position, nor move his head, without much pain; he gradually wasted away. He expired suddenly, in the act of being raised from his pillow ; probably from the anterior ligament of the processus dentatus at that moment giving way. A slight tendency to paralysis of the upper extremities was observed on the morning of the day he died.__T. DISEASES OF THE ENCEPHALIC MEMBRANES. 49 whatever drink she took. On the fourth day, still vomits; hysteri- cal symptoms gone; she entered the hospital in the evening, and on the following morning presented the following state:—fifth day, countenance very much flushed ; eyes very bright; neck swollen ; head turned back and flexed laterally, could not be inclined forward without causing great pain; constant pain extending along the ver- tebral column, from the great occipital foramen to the sacrum ; the least movement causes the patient to scream from pain; pain not increased by pressure; respiration embarrassed, and panting; pulse frequent; skin hot and dry ; tongue natural ; had no stool for the last forty hours (fifteen leeches to the anus ; purgative enema ; mustard pediluvia ; demulcent drinks ; soothing frictions over the spine). Sixth day, pain less (blister to the nape of the neck ; twenty-four leeches behind each ear). Seventh day, sleep disturbed ; increased sensibility of the head and back ; tetanic rigidity of the back of the neck and trunk : countenance pale and expressive of pain ; respiration more painful than before ; pulse the same (bleed- ing from the arm ; blister to the sacrum ; sinapisms to the legs ; assafoetida enema). Three minutes after the bleeding, the blood was buffed and cupped ; at the end of an hour, the patient very much relieved in every respect, and the bleeding was repeated. Some delirium on the eighth day, when she Was bled again. On the ninth, the blood drawn exhibited the same inflammatory appearance as that of the two first days ; pain of head and back more intense ; features sharpened and very much changed ; answers to questions slow and painful—(twenty-four leeches along the vertebral column ; laxative enema). At four o'clock in the evening, she no longer answers questions ; constant moaning; subsultus tendinum; pulse small and frequent; respiration short. On the tenth day, cold and clammy sweat over the face ; all the other symptoms were aggra- vated, and she died at noon. Post mortem.—The spinal canal was opened through its entire extent, and on cutting into the dura mater we found a layer of whitish, opaque, membranous matter extended over the spine, from the great occipital foramen to the sacrum ; on pressing it with the finger, a turbid liquid, mixed with albuminous clots, are made to flow into the cranium ; on drawing the scalpel over this membra- nous layer, the instrument slides on and takes up nothing, which seems to indicate that there is a membrane above this layer ; dissec- tion soon proves it. On detaching the arachnoid from the inner surface of the dura mater, we discover that the diaphanous membrane covering the purulent layer, is but a continuation of it; it is evidently the portion of the arachnoid which, under ordinary circumstances, covers the pia mater, and which is here separated from it by a layer of pus. Here then the pus is found exhaled, not into the cavity of the serous membrane, but on the external surface of this membrane, in the cellular tissue uniting it to the pia mater. On the brain, the arachnoid and pia mater are very much injected towards the fissure of Sylvius. On the rightside we findan albuminous concretion, similar to that which 50 ANDRAL'S MEDICAL CLINIC. fills the vertebral canal ; we also find another, still thicker, on the external surface of the right hemisphere, near the great interlobular fissure. Concretions similar to the preceding are found beneath the tentorium cerebelli, and a still greater quantity than elsewhere between the lower surface of the cerebellum and the base of the cranium. The lateral and third ventricles were very much dis- tended by a great quantity of milky serum. Thoracic and abdomi- nal viscera sound. Remarks.—This case presents a combination of the different symptoms which characterise, in the most striking manner, acute inflammation of the membranes of the spine. Yet at first, it did not commence by these symptoms ; it might have even been taken for a simple neurosis, and probably it was then nothing more ; we think that there are many cases of this kind, and that some inflam- mations are preceded by mere nervous disturbance, in which the disease then entirely consists ; at which moment, narcotics have a marvellous power of dissipating the symptoms, but if it be allowed to proceed, it will soon change its nature ; and those functional dis- turbances which, a while ago, were the expression of an affection merely of inervation, will afterwards be produced and kept up by an inflammatory process, where narcotics would be mischievous, and other means must be resorted to. During this first period, which appears altogether nervous, those vomitings also appeared, which are so often connected with cerebral affections, mark their onset, and precede their characteristic symp- toms. It is only from the fourth to the fifth day, after the appear- ance of these different symptoms, that the first phenomena, indica- tive of the nature and seat of the disease, disclosed themselves. The intellect remained for a longtime unaffected ; whilst, on the contrary sensation and motion became seriously altered. In none of the preceding cases have we seen anything similar to the acute pains felt all along the vertebral column, accompanied by some tetanic symptoms. Cerebral meningitis also existed ; and it is not impro- bable that the inflammation ascended from the spinal canal into the cranium only towards the termination of the case. We are disposed to consider that the difficulty of respiration arose from the circum- stance of the spinal cord, in which we include the medulla oblongata, being the special seat of the disease. The moral cause which brought on the suppression of the catamenia is an additional reason for our considering that the affection, in the first instance, was merely nervous. Case 27.—Spontaneous luxation of the first two cervical vertebra—Hemiplegia. A man, thirty-five years of age, of a strong constitution, had always enjoyed good health, except that he twice had syphilis, for which he says he was properly treated. After having suffered considera- bly from pains in different parts of the body, in the left knee in the region of the kidneys, and the left thigh, he was then attacked with pain in the left side of the head, which soon spread to the DISEASES OF THE ENCEPHALIC MEMBRANES. 51 same side of the face ; some time after he began to complain of his neck, the motions of which became very much constrained ; about a month after this the patient discharged by the mouth a great quan- tity of pus. The medical man who saw him at this time thought that the purulent discharge came from an abscess which formed between the pharynx and vertebral column, and which opened into the pharynx. However it ceased at the end of seven days ; but from this period the patient's countenance changed rapidly ; he wasted away ; continued to feel pain in the left side of the neck, his head inclined over the right shoulder, and his face was directed towards the same side. Some weeks after, the fingers of the left hand became the seat of a pricking sensation ; the day after they were, as it were, benumbed, and could not be moved without diffi- culty ; the day following, the entire upper extremity of the left side was deprived of motion ; next day he felt the lower extremity of the left side a little weaker than the right. He entered the hos- pital on the 10th of June, and presented the following state : lies on his back, head and face inclined to the right, without any sensi- ble contraction of the sterno-mastoid muscles ; lancinating pain throughout the left side of the head ; left pupil not so much dilated as the right; conjunctiva of this side considerably injected ; left eyelid hangs a little over the eye ; vision equal on both sides ; intel- lect sound ; total loss of the contractile power of the left arm ; its sensibility entire ; perceptible diminution in the motions of the left lower extremity ; tongue a little red. There was an issue in the nape of the neck, which was still retained. On the day after, the head having been a little deranged from his position during the dressing, and inclined somewhat to the left as also the face, the two extremities of the right side instantly lost the power of moving ; they recovered it the moment the head resumed its usual position. On the nights of the three following days, delirium set in, pulse frequent. Sinapisms were ordered. Two days after, at six o'clock in the morning, the patient was in the same state as on the preced- ing days ; he conversed quietly with the other patients who were near him, and there was no sign as yet of his dissolution being at hand. At seven o'clock he suddenly lost the faculty of speech ; his body was covered with a cold sweat, his respiration became remarkably slow, then stopped altogether, and he died at half-past seven. Post mortem.—25 hours after death. The brain being examin- ed with the greatest care, presented no appreciable lesion in its sub- stance ; its ventricles were nearly empty ; the external arachnoid was considerably injected. Immediately on separating the pons Varolii from the medulla oblongata, we perceived sanious pus of a reddish grey colour flow in great abundance from the great occipital foramen. The transverse ligament of the atlas which separates the spinal cord from the ondontoid process, was entirely destroyed, and this process Was in immediate contact with the cord, which being pressed by it was transformed on that part into a soft pap.— 52 ANDRAL'S MEDICAL CLINIC. The entire process was rough and uneven. The superior articulating cavity of the atlas on the left side did not hold by any ligamentous connection or any capsule to the condyle of the occipital bone ; both presented a dark rough appearance, and were bathed in and im- mense quantity of pus. The left portion of the posterior arch of the atlas was also carious. The inferior articulating process of the atlas, and the superior process of the dentata of the right side, were also separated from one another, and their surface were black and rough. Finally, the left portion of the anterior surface of the body of the dentata was equally deprived of periosteum, and presented numerous asperities; it was separated from the pharynx by a puru- lent collection of a dirty grey colour, which communicated with this passage by a fistulous opening, the orifice of which corresponded to the fourth cervical vertebra. Remarks.—Let us now endeavour to connect the lesions found after death with the symptoms during life, and let us see how far the one may clearly explain the other. In the first place, it is evident that the purulent discharge which took place by mouth, about two months before death, had the origin ascribed to it by the medical man who saw him at the time ; it is probable that some pus flowed every day through the fistulous opening in the posterior wall of the pharynx ; but coming only in small quantities at each time, it passed probably into the stomach. It is again probable that the disease of the first two cervical vertebrae commenced long before it manifested itself by any well-marked symptom ; but in proportion as this disease advanced, the different ligaments securing the con- nexions of the occipital bone and the first two vertebrae, were des- troyed, gradually, and at last became totally disorganised. As soon as this destruction was carried to a certain degree, the displacement of the articulating surfaces was the inevitable consequence ; thence compression of the cord by the luxated vertebrae. There was a luxation on the right as well as on the left. The inclination of the head and face to the right shows that the displacement took place principally on the left, at the atloido-occipital articulation ; the par- alysis also existed on this side. One day a momentary paralysis was noticed on the right side, in consequence of a slight change in the position of the head. This circumstance is easily accounted for, by supposing that in this change of position the diseased articulating surfaces of the right side came to ride one over the other. The permanent inclination of the head without contraction of the sterno-mastoid muscles, might have inclined one to suspect luxation of the vertebrae. The manner in which the head inclined over the shoulder, without the neck seeming to participate in this flexion, as happens in the natural movements, indicated that the luxation took place very high up. It must be admitted that at first the odontoid process underwent but very slight displacement.__ But a period arrived when, whether after some sudden movement or in consequence of the destruction of the transverse ligament, the spinal marrow came to be compressed and disorganised by this DISEASES OF THE ENCEPHALIC MEMBRANES. 53 process. This phenomenon may be referred to the time when the patient suddenly lost the faculty of speaking, and when his res- piration became embarrassed ; death supervened as soon as the disorganization of the cord was such as to incapacitate it for the discharge of its functions. Some would connect the caries of the vertebrae in this case with the syphilitic attack under which the patient had previously laboured. Case 68.*—Phenomena obscure at the commencement of the disease—Constipation- Retention of urine—The fifth day, paralysis affecting the motion of the lower limbs with morbid exaltation of the sensibility—Rigidity of the neck and trunk, accompa- nied with pains along the spine on raising the patient.—The seventh day, the same phenomena in the upper extremities, but in a less degree—They became a little rigid—Symptoms gradually became more severe—Death at the commencement of the tenth day—Puriform exudation between the arachnoid and pia mater of the cord— Injection of the cerebral vessels—Turbid serum in the ventricles. A man, twenty-four years of age, of rather a strong constitution, entered the Hotel Dieu, the 19th of October, 1823, stating that he had been ill for the last five or six days. He complained of no par- ticular part as being the seat of acute pain ; his illness was general, but slight. ; still his countenance was expressive of suffering ; his answers were slow ; lips seemed to tremble as when a person is going to cry ; no appreciable symptom of fever ; heat of skin natural; no symptoms of gastro-intestinal irritation. He remained for two days without undergoing any change. He arose out of bed and walked through the ward, but not having passed any urine since entering the hospital (three days), the catheter was introduced ; bladder very much distended. On the 24th Oct. (fifth day) M. Dance examined the patient more particularly ; his countenance still expressive of suffering ; seems always as if going to weep ; an- swers slow and vague, when questioned regarding his state, about which he does not furnish any more information ; bladder still dis- tended ; on raising the lower extremities he screams with pain, particularly on moving the right lower extremity ; pinching felt equally in both limbs ; sensation also perfect, but he cannot raise them ; he cannot even extend them after they have been flexed ; they fall back on the bed as inert masses, if left to their own weight; they are deprived of motion but not of sensation. The vertebral region was then examined, which presented nothing unnatural ; it was remarked that he could not replace himself on his seat; that he suffered on the least flexion of the spine, and that the neck was slightly retroverted ; on attempting to incline it for- ward, it could be done only to a certain degree, and by causing the patient some pain ; he was now very irritable. In the upper ex- tremities motion and sensation underwent no change ; pulse has some frequency and a little hardness ; skin hot ; tongue natural; no stool for the last five days ; no rigidity nor convulsions in the lower * A few cases of Spinal Meningitis are here added from Ollivier's Treatise on Diseases of the Spinal Cord. The numbers annexed to the cases refer to Olli- vier's work.—T. Sept. 1838.— N- 7 54 ANDRAL'S MEDICAL CLINIC. extremities (venesection, enemata). On the 25th, same state ^dis- tention of the bladder ; pulse frequent ; skin hot; limbs painful when moved, particularly that on the right side ; same state of coun- tenance and slowness in the association of his ideas ; same pain on turning the patient (another bleeding). On the 26th the same ap- pearance ; pulse now very small and more frequent ; bladder still distended ; urine fetid, turbid and reddish, contains a gaseous fluid which is heard escaping by the catheter, which is blackened by re- maining even for a short time in the bladder ; blood last drawn buffed and cupped. In the evening state worse ; pulse nearly ex- tinct and very frequent ; still the heart beats with considerable strength ; lower extremities sensible, but cannot move, and are very painful when any one attempts to move them. This paralysis and morbid sensibility begin to appear in the upper extremities, which present a slight rigidity ; trunk and neck rigid ; countenance still expressive of suffering ; answers slow but precise ; tongue moist; evacuations from the bowels scanty. On the 27th same state ; parietes of the bladder have now lost all contractility ; upper extremities weaker ; one stool (sinapisms to lower extremities). On the 28th, patient now much worse in every respect ; the con- tractile power of the upper extremities weakened ; they are half- flexed, and evidently rigid, as are the entire trunk and neck ; head somewhat inclined backwards and to the left ; right pupil more dilated than the left; respiration slow ; motions of ribs incomplete ; bladder still distended ; escape of fetid gas with the urine through the catheter ; no stool. Died on the 29th, the tenth day of the disease. Post mortem thirty hours after death. Cerebrospinal Cavity.—Marked injection and distention of the spinal vessels ; membranes healthy ; lateral ventricles very much distended, containing about three-fourths of a glass of serum, some- what opaque ; the other ventricles were also distended. The vertebral canal being opened through all its extent, we observe, external to the dura mater, in the cellular tissue surrounding it, a net-work of vessels injected with blood. This membrane seemed very much distended and immediately applied to the cord, which already indicated a particular development of the parts contained in it. The dura mater having been cut into through its entire length, the cord appeared covered by a gelatinous layer, slightly yellowish, four or five lines thick, which was applied immediately over the pia mater. This layer was very thick towards the lumbar enlargement of the cord, and there also the yellowish colour was deeper ; it gradually diminished in thickness in ascending as far as the third or fourth cervical vertebra, where it ceased altogether ; there was no trace of it on the cauda equina ; it was less thick and less perceptible on the anterior surface of the cord than on the posterior surface. This gelatinous layer was situated between thetpia mater of the cord, and the corresponding arachnoid reflexion ; that which lined the dura mater was also covered with a very delicate false membrane DISEASES OF THE ENCEPHALIC MEMBRANES. 55 granulated, and of little consistence. This puriform, concrete sub- stance, subjacent to the arachnoid, was not liquid, whether by reason of its tenacity, or because it was contained in the meshes of the sub- arachnoid cellular tissue. The lower part of the spinal canal, beneath the arachnoid, contained four or five spoonfuls of opaque serum. Thorax.—Lungs adhering at all points of their surface, by organ- ised cellular bands of long standing ; the right lung posteriorly, was evidently in the first degree of hepatisation ; its tissue friable and gorged with blood ; heart natural. Abdomen.—Mucous membrane of the stomach plaited, grey, slate-coloured,and even somewhat bJackish,for a considerable portion of its extent; in some parts it was studded with red dots, as if from ecchymosis ; that of the intestines was very much injected, reddish, and the intensity of this colour, which occupied the lower fourth of the intestine, went on increasing as far as the ileo-caecal valve ; the mucous membrane of the bladder was thickened, reddish, slate-co- loured, evidently inflamed, and filled with thick, fetid urine. Remarks.—This case presents, in a manner, the complete history of spinal meningitis, and the symptoms of this inflammation, were, as we see, conformable to the lesions found on the dead body ; the invasion of the disease was obscure ; the patient remained four days in the hospital before we were able to determine what his disease was. The first four days he arose out of bed and walked about the ward ; so that it is evident the locomotive powers were not affected till the fifth day ; up to that period, paralysis of the bladder and retention of urine were the only symptoms that could create any suspicion of leison of the spinal cord or its membranes ; the func- tions of the intestines were at the same time destroyed, and consti- pation existed nearly from the commencement of the disease till death. Paralysis of the motive power of the lower extremities, with morbid exaltation of the sensibility, are the phenomena which then appeared, and to which were joined rigidity of the neck, inflexi- bility of the trunk, pains in the trunk and limbs on moving these parts. Such was the series of the symptoms which manifested themselves successively in the course of the spinal meningitis. Again, if we consider the peculiar appearance of the countenance, the difficult association of ideas, the slowness of his answers, which were noticed from the commencement, it may probably be supposed that the cerebral leison preceded that of the membranes of the cord : so in fact it appears to me ; but the changes found in the encephalon, and which are also entirely conformable to the state of the cerebral functions during the disease, were not of a nature to have influenced the progress of the spinal meningitis ; they probably contributed to throw obscurity over its first progress. What makes it probable that they could not exercise any influence on the progress of the spi- nal meningitises, that the latter manifested itself by symptoms which proved its ascending progression,and its commencement in the lower portion of the cord. It may be remarked, that the neck becoming 56 ANDRAL'S MEDICAL CLINIC. rigid, and the upper extremities losing their strength, were subse- quent to the paralysis in the motion of the lower extremities. 1 he muscular movements were abolished in the bladder, the Jntestl"e» and the lower extremities, whilst the upper extremities had lost but a portion of their motive power ; and the pseudo-membranous layer was found, in the dead body, much thicker infenorly than supe- riorly, which seemed to indicate that the inflammation had been ot longer duration, and of a less recent date in the former region. The pain felt by the patient on moving the limbs or trunk, may, perhaps, be explained bv the slight dragging, or shaking, which the inflamed membranes of the cord then suffered ; the same phe- nomenon being also observed in pleuritis, where the slightest pressure increases the sufferings of the patient. The involuntary contractions of the vertebral muscles, which rendered the spine like an inflexible stock, seem also the result of those instinctive motions which we so often execute for the purpose of avoiding or preventing pain. The vertebrae, by becoming fixed one upon the other, prevented the spinal membranes from experiencing so much dragging. The morbid exaltation of the sensibility seems to be one of the characters of spinal meningitis. According to Lallemand, the sensibility is not as often abolished as the power of motion, because the nervous centres are in two very different physiological conditions in the production of motion and of sensation ; they are active in the performance of the former, whilst for sensation they are merely passive; they only receive the impres- sion. The rigidity and semi-flexed state of the upper members observed in this case, support M. Lallemand's opinion, who considers convulsion and rigidity of the limbs as a symptom of inflammation of the coverings of the nervous centre. In this case, traces of inflammation were found in the lungs, stomach, and bladder. The state of the lungs may be easily accounted for by the difficulty of the respiration during the last period. The state of the stomach and intestines gave rise to no symptom, except we refer to it the burning heat of skin, and the great thirst. We are inclined to think that those inflammations so often met in these cases are the effect of sympathic re-action, and of the numerous connexions uniting the spinal cord to the respiratory and digestive organs. With respect to the cystitis, it was attributable no doubt to the decomposition of the urine, and to the irritation caused by the sound in the bladder. What was remarkable in this case, is, that the symptoms were con- tinued, those painful tetanic contractions so characteristic in such affections, which come on at irregular periods, and are followed by more or less remission, not having been here at all observed. DISEASES OF THE ENCEPHALIC MEMBRANES. 57 Case 72.*—Permanent tetanic contractions, accompanied with symptoms of cerebral meningitis—Death on the ninth day—Puriform exudation at the base of the left hemisphere, and in the middle of the dorsal region, under the arachnoid—Gelatinous infiltration of the cellular tissue, external to the spinal dura mater. A male child, between three and four years of age, was brought to the Hbpital des Enfans- Trouvis. The first symptoms were very great difficulty of deglutition ; remarkable fixedness of the eyes, to which soon joined tetanic symptoms : trismus, opisthotonos.—(Re- peated application of blisters behind each ear, sinapisms to the lower extremities, frictions, tepid baths produced no amelioration.) The child was continually comatose. Died on the ninth day. Post mortem.—Cranium.—Cerebral substance very much in- jected and firm ; the grey substance of a very deep colour ; white substance of a pearly aspect, containing some injected vessels, parti- cularly around the ventricles, which contained a considerable quan- tity of serum. Their lining membrane thickened and injected.— That of the lower part of the left hemisphere was covered by a thin albuminous concretion, and the same membrane presented a very bright red injection on the convexity of the two hemispheres, and in some parts of the cerebellum. Spine.—In the middle of the dorsal region, there was a reddish infiltration of considerable consistence, in the cellular tissue between the dura mater and the bony canal of the spine. On making an incision into the membranes, their cavity was found filled with serum ; the vessels on the surface of the pia mater were very much injected, in the middle of the dorsal region only, where the arach- noid covered an albuminous concretion of about four inches in length, The substance of the cord a little more injected than natural. Thorax.—The pleura pulmonalis of the right side adhered to the pleura costalis and to the diaphragm by a false membrane of some thickness, and not organised. Abdomen.—The stomach, which was contracted on itself, con- tained some frothy mucus. The mucous membrane of the small intestines also was covered with a grumous whitish mucus. That of the large intestines was of an intense red colour, through all its extent. The mesenteric ganglia were very large, soft, and white. Liver pale. Remarks.—The spinal meningitis, though circumscribed, contri- buted no doubt to cause the tetanic contraction of the trunk in this case ; yet we must also take into account that the cerebral meningi- tis must also have exercised some influence in producing this phe- nomenon, it alone being in some cases sufficient to produce the re- troversion of the neck. It is evident from this case that inflamma- tion of the membranes of the cord may be confined to a portion of their extent more or less circumscribed ; we shall presently see another case fully demonstrating this pathological fact. There was also found a gelatinous and reddish infiltration in the oellular tissue, * Ollivier, vol. ii. p. 585, 7* 58 ANDRAL'S MEDICAL CLINIC. external to the dura mater ; and I shall here remark, that this change appears to be sometimes the sole product of spinal inflammations.— The existence of thoracic and abdominal inflammation, which is so frequent a coincidence with affections of the spine, is to be set down as a consequence of the physiological and pathological relations connecting this nervous centre with the different apparatuses of or- ganic life. Case 73.*—Deep-seated pain in the lumbar region, after a violent effort; cerebral symptoms followed by debility, and partial paralysis of the limbs; urine and faeces discharged involuntarily—Death twelve days after the appearance of the latter symp- toms—Effusion into the right ventricle; meningitis of the convexity of the left hemi- sphere ; capillary injection, of about an inch in extent, beneath the arachnoid of the meningeal sheath of the cord in the lumbar region. A man, twenty-eight years of age, entered the hospital La Charite, April 4, 1823. He had been treated at the Saint Louis for a deep- seated pain which he felt in the lumbar region, after a violent effort to raise a load in September, 1822. A blister was applied over the seat of pain, which was very long in healing. On entering La Charite", he complained of general debility ; he was very much dejected, and considerably emaciated. On the 7th of the month, he presented the following symptoms :—extreme difficulty in answer- ing questions, inability to articulate certain words ; mouth slightly inclined to the right ; face a little red ; left arm weaker than the right; sensation and motion of the lower extremities natural ; urine and faeces passed involuntarily—(arnica, blisters to legs, purgative clyster). On the 8th, several stools, pulse slow ; mouth straight, countenance pale ; unable to articulate one word ; motion of the left arm more difficult than that of the right—(volar, linim. with tinct. cantharid. to be rubbed on the limbs). On the 9th, both arms move equably ; loss of consciousness. On the 10th, deglutition impossi- ble ; he manifests some pain when his legs are taken hold of to dress the blisters; respiration frequent, not stertorous. Died at ten o'clock in the morning. Post mortem (twenty-two hours after death). External appear- ance.—General emaciation ; great rigidity of the limbs ; chest flat- tened and narrowed. Head.—Vessels of the brain gorged with blood, patches of a yel- lowish grey colour on the surface of the left hemisphere, formed by a concrete substance effused under the arachnoid ; considerable serous effusion into the right ventricle. Spine.—Whitish turbid serum (about an ounce and half) in the lumbar portion. On the right side a sort of ecchymosis, an inch broad, formed by a number of small capillary vessels injected, subja- cent to the arachnoid lining the dura mater ; the injection deeper in the centre; the arachnoid was neither thicker nor more opaque on this part, which corresponded to about the third vertebra. Its inner * Ollivier, vol. ii., p. 589. DISEASES OF THE ENCEPHALIC MEMBRANES. 59 reflexion was separated from the pia mater of the cord, posteriorly only, by a frothy serum which diminished towards the upper part. Thorax.—Some adhesions of the left lung to the pleura. Its inferior lobe presenting pneumonia in the third stage ; pus escaped from it on making an incision ; upper lobe filled with miliary tuber- cles in different degrees of softening. It crepitated however.— Entire of the right lung adherent, crepitating, filled with grey gra- nulations. Abdomen.—Liver occupies the two hypochondria, concealing the stomach ; it was gorged with blood. Veins of the stomach dilated. Small intestines presented some partial redness in their interior.— Bladder dilated, urine deep-coloured, fetid, not ammonical ; its mu- cous membrane pale. Remarks.—The continuance of the pain in this case, and the rela- tion existing between its seat and that of this isolated inflammation, incline us to think that the effort made to raise the heavy load had been the cause of it. The patient was in some respect cured of this when he entered the hospital, and died of cerebral meningitis.— The turbid liquid found in the spinal membranes came probably from the cavity of the cranium, being a portion of "that which dis- tended the ventricles. The cases now given belong to acute spinal meningitis ; and the symptoms, as well as the changes found after death, show what great influence the spinal cord possesses over the organs of nutritive life, in which we very frequently find evident traces of an inflammation which was developed during the course of the spinal affection. But when the meningitis is chronic, its symp- toms are less obvious, consisting merely in obscure pains of the back, with a feeling of restraint and fatigue in the limbs, and the attention is in general exclusively directed to the morbid phenomena which arise from the vicera secondarily affected, the true causes of which are too often misunderstood. Colouring mere or less deep of the membranes, and a thickening of them are the ordinary anatomical characters of this chronic inflammation, which also usually leaves after it cellular adhesions between the arachnoid and pia mater, and between the two arachnoid reflections. 60 ANDRAL'S MEDICAL CLINIC. RECAPITULATION. CHAPTER I. LESIONS DETECTED IN THE MENINGES BY POST MORTEM EXAMIN- ATIONS. ARTICLE I. Lesions of the Dura Mater. Lesions in the dura mater are much more rarely met with than in the two other cerebral membranes. In the cases already detailed, there are two which present remarkable instances of tumours de- veloped on the inner surface of the dura mater, one of them being seated in that portion of the dura mater which is in contact with the vault of the cranium, whilst the other was formed on one of the two portions of the tentorium cerebelli. These* tumours had a texture analogous to that of the dura mater itself. One of them was constituted exclusively of fibrous tissue. In the other there was mixed with this fibrous tissue a certain quantity of ossiform matter. Both these anormal products bore a strong resemblance to the fibrous bodies of the uterus. In the two cases, the nervous sub- stance was rather wasted than compressed, where it was in contact with the tumours. In one of these cases we could not refer the disease of the dura mater to any appreciable cause. In the other case, it was after external violence inflicted on the occipital region, that the tentorium cerebelli became the seat of the osteo-fibrous vegetation already described. Here then is one of those cases wherein we must have recourse to the existence of a disposition altogether peculiar, in order to explain those infinitely varied lesions which one and the same cause is capable of producing. One of our cases presented us with a considerable ossification of the great fold of the dura mater, known by the name of the falx cerebri; this is the part of the dura mater most frequently incrusted with calcareous phosphate. In two cases where it presented no trace of ossiform substance, this falx was transformed, for almost its entire extent, into a large plate of cartilaginous texture. The very fine cellular tissue interposed between the proper tissue of the dura mater, and that of the arachnoid lining its inner surface, has presented to us some lesions worthy of remark. First, we have * These tumours are different from the fungoid tumours which appear to be connected with thearachnoid of the dura mater; they arise from the structure of the dura mater itself, with which they are intimately joined, and from which they are inseparable without tearing that membrane.—Bright, vol. ii. 663. For a highly interesting case of tetano-epileptic convulsions, where a bony deposition was found in the falx, as reported by Dr. James Johnson, See Medico- Chirurg. Review, April 1835__T. DISEASES OF THE ENCEPHALIC MEMBRANES. 61 found in it those cartilaginous or bony plates mentioned above, and we have elsewhere* shown that the ossifications of fibrous mem- branes are much more frequently seated in the cellular tissue, im- mediately touching these membranes, than in their own proper tissue. On one occasion we found the arachnoid separated from the por- tion of dura mater corresponding to the arch of the cranium, by small depositions of pus, between which the membranes appeared quite sound. These depositions were five in number, and existed only on the left side: each of them appeared as a white layer, from three to four lines thick, interposed between the arachnoid and dura mater. There was at the same time sero-purulent infiltration in the subarachnoid cellular tissue of the convexity of the hemispheres. We have never met a case of serum being effused between the arach- noid and dura mater. ARTICLE II. Lesions of the Arachnoid A The lesions of the arachnoid, as those of other serous membranes, are principally referrible to its products of secretion. This may be modified in different ways, though at the same time the arachnoid does not receive more blood than usual, and may not have under- gone in its nutrition any appreciable modification. It should not be admitted that the arachnoid has been the seat of a morbid secretion, except when the product of this secretion is found in its cavity. Now this case is itself much more rare than that in which the morbid product is found outside the arachnoid, in the cellulo-vascular tissue constituting the pia mater. The morbid products found in the cavity of the arachnoid are the following:— 1. An effusion of clear, transparent serum. Such an effusion is very rare on the upper surface of the brain; it is more common at the base, towards the occipital fossae. 2. An effusion of turbid, milky serum, with purulent flocculi. We have seen but one instance of this sort in the great cavity of the arachnoid. 3. False mem- branes not yet organised, lining one or other of the free surfaces of the arachnoid. 4. False membranes of longer standing than the preceding, of serous organisation, extended over one or other free * Pathological Anatomy. | The arachnoid and pia mater are so intimately connected as to be scarcely separable from each other, except at the base of the brain.....The arachnoid of the adult in its healthy state is supposed to possess very little vascularity ; but its substance is so delicate, that the vessels of the pia mater are distinctly seen through it; and when fluid is effused into the cellular membrane of the pia mater, some of the vessels appear evidently to lie on the surface of the fluid, as if they belonged to the arachnoid, and do not dip down between the convolutions. —Dr. Bright, M.R., vol.ii. p. 669.—T. 62 ANDRAL'S MEDICAL CLINIC. surface of the arachnoid. 5. Adhesions of a cellular appearance, similar to the bands of the pleurae, and extending from one of the free surfaces of the serous membrane to the other. There are some cases in which, instead of any of these anormal products, we have found nothing but remarkable dryness of the arachnoid on the sur- face not adhering. It would appear that in such a case there had been, during the last period of life, a suspension of the exhalation of the fluid, which ordinarily gives to this membrane a certain de- gree of polish and moisture. With or without these latter degrees of alterations of secretion, we have never observed in the arachnoid the least vascular injection; neither have we ever seen in it either change of colour or thicken- ing. It appeared to us that the cases wherein the arachnoid appeared at first view either coloured or thickened, were cases where there was lesion of the subjacent cellular tissue. Whatever be the nature of the delicate membrane lining the inner surface of the ventricles, this membrane presents, in the pathologi- cal state, nearly the same lesions as thearachnoid developed around the brain, but the former are more frequently met with. It is much more common, for instance, to find serum effused in considerable quantity into the ventricles than into the great cavity of the arachnoid covering the convexity of the hemispheres. The presence of this serum in the ventricles should be considered as the result of a morbid process only when its quantity exceeds an ounce in each lateral ventricle. When it is very abundant, it raises the upper wall of the ventricle, and, on pressing gently with the finger, this wall presents a manifest fluctuation. In such case there can be no doubt but that the accumulation of serum in the cerebral cavities is a morbid phenomenon. We seldom find any perceptible differ- ence in the quantity of fluid contained in each ventricle. When- ever this quantity was very considerable, we have found the septum lucidum and the fornix very much softened. In some cases we have seen the two laminae of the septum lucidum separated by serum, and the cavity of the fifth ventricle thus become accidentally quite manifest. Instead of limpid serum we occasionally meet in the ventricles a turbid liquid, in which are observed those flocculi, called albuminous, which constitute so frequent an anatomical character of pleuritis or peritonitis. In some of the cases which came before us, we have seen the ventricles filled with a collection of real pus, which, by reason no doubt of its greater weight, was found accumulated in great quantity, principally at the lower part of each lateral ventricle, or in the ancy- roid cavity. In most of the cases where pus was found within the lateral ven- tricles, some was also observed at the same time in some points of the sub-arachnoid cellular tissue surrounding the nervous centres. The membrane yielding these varied products, once presented to our view some finely injected vessels, which lined as a net-work the DISEASES OF THE ENCEPHALIC MEMBRANES. inner surface of the parietes of the ventricles. In all the other cases, in those even where pus filled the ventricular cavities, no appreciable lesion appeared in the membranes lining their parietes. We do not, in fact, consider as an alteration of nutrition in this membrane, but as a product of morbid secretion, small granu- lations,* which are sometimes seen scattered on the inner surface of the ventricular parietes, a remarkable specimen of which we ob- served in one of our cases. ARTICLE III. Lesions of the Pia Mater. These have been much more frequently observed than lesion of the two other membranes. The lesions which this membrane has presented are the following: 1. Infiltration of its tissue by a clear, colourless, transparent serum. Sometimes this serum forms but a thin layer interposed between the arachnoid and the cerebral substance; sometimes ac- cumulated in more considerable quantity beneath the arachnoid, it raises this membrane, and distends the cerebral anfractuosities. 2. Infiltration of the tissue of the pia mater by a turbid, milky liquid, and sometimes by real pus.t The latter has sometimes a remarkable consistence; it is as it were intimately combined with the cellulo-vascular tissue within which it is formed ; it is concrete like certain pseudo-membranes of the pleura or peritonium. 3. A real state of scirrhous induration of the tissue of the pia mater. We once saw such a state ; between the arachnoid and the circumvolutions of the cerebral hemispheres there was a layer of solid matter, of a bluish grey, from five to six lines thick. This layer existed over nearly the entire extent of the convexity of the two hemispheres. 4. Serous cystst variable in size and number. These may, in proportion as they become developed, compress the cerebral sub- * This is a result of inflammation of the surface of certain parts becoming sca- brous, as if covered with fine sand; this appearance takes place in different parts, and is frequently very manifest about the foramen of Munro, or the peduncles of the pineal gland.—Bright, vol. ii. 692.—T. J This is an undoubted result of inflammatory action, filling the meshes of the pia mater with a semi-fluid substance of a colour much resembling pus ; it is not effused upon the surface of the arachnoid, nor does it remain upon the sur* face of the brain; but when the membranes are drawn off, it separates with them, leaving the convolutions quite exposed, and when an incision is made into the membranes, none of the yellow deposit escapes.—Bright, vol. ii. 674.—T. X These serous cysts appear to be placed between layers of serous membrane, or to be contained in adventitious membranes; they vary from the size of a pea to that of an orange; they are of a most chronic character, often give no symp- toms by which their existence is even suspected, and are probably coeval with life, not only the brain, but the bony parietes being often moulded to their form. —Bright, vol. ii. 675—T. 64 ANDRAL'S MEDICAL CLINIC. stance more and more, and thus become, in a way altogether me- chanical, the cause of different phenomena. 5. Cartilaginous, or osseous plates, which we have seen in one case cover, like a second arch, the anterior fourth of the convexity of one of the cerebral hemispheres. 6. Tubercles, sometimes few in number and scattered over a broad surface, sometimes numerous and collected together, and forming, by their union, homogeneous whitish masses, which, on the one hand, compressed the arachnoid, through which they were seen, and which, on the other hand, sunk deep into the circumvolutions, the tissue of which they compressed. In one case, where these tubercles were thus collected, the pia mater had, at the same time, contracted such intimate adhesions with the cerebral substance, that the latter was detached in large portions along with the pia mater. It often happens that tuberculous matter is deposited between two circumvolutions, the interval between which it perfectly fills up. It then happens that the two portions of pia mater, covering eacb cir- cumvolution, come to form strong adhesions to each other, and in such case, a cursory examination might incline us to think that it was in the parenchyma of the brain that the tubercular matter was deposited. 7. Adhesions.—These are formed between the portions of pia mater leaving the arachnoid in order to line the interior of an an- fractuosity. Then this anfractuosity completely disappears, and several circumvolutions are observed as it were soldered together ; they are so firmly united that they cannot be separated unless by tearing them. In concluding this enumeration, let it be observed, that most of the lesions of which medical writers place the seat in the arachnoid, and which they consider as the anatomical characters of arachnitis, reside most frequently in the pia mater. In almost all the cases, for instance, where the convexity of the cerebral hemispheres was covered with a layer of serum or pus, this layer had its seat beneath the arachnoid ; on passing the back of the scalpel over the latter membrane, the morbid product is displaced, but not removed. Sometimes this product is so extensively connected with the cellulo-vascular tissue, interposed between the arachnoid and brain, that it cannot be displaced even by the process just now mentioned. Every time we found tuberculous matter deposited around the nervous centres, in their enveloping membranes, it was not the arachnoid that appeared to contain this product of morbid secretion; it filled the meshes of the pia mater. We might say as much of the cartilaginous or bony concretions occasionally found in the form of grains, or plates, more or less extensive, around the substance of the brain or spinal marrow ; here too it was the pia mater which appeared exclusively to be the seat of them, except in the case above noted, where these concretions were developed between the arach- noid and dura mater. In fine, it is in the pia mater also that we find those small bodies, DISEASES OF THE ENCEPHALIC MEMBRANES. 65 commonly known under the name of Glandulse Pacchioni, which, in some subjects, are found in great numbers towards the edge, which separates the upper part of the internal surface of each cerebral hemisphere, but the existence of which is far from being constant. We think, with several other persons, that these bodies, so impro- perly called glands, are a morbid product formed in the pia mater, and that they should no more be considered as a condition of the normal state, than should those cellular bands in the pleura, which, in consequence of their great frequency, some ancient authors have considered to be a physiological product. In fact, these bands have been designated, in old anatomical writings, by the name of ligaments of the pleura. If we now come to consider simple redness, and the different degrees of injection which the membranes may present, we might still further confirm by our own observation what has .been said by Chaussier and others ; we should find that this redness, more or less bright, more or less extensive, has, ninety-nine times in a hundred, its exclusive seat in the pia mater, and that above the latter the arachnoid remains transparent and colourless. However, whilst we admit that in the diseases designated by the name of arachnitis, or more properly meningitis, anatomy discovers lesions in the pia mater much more frequently than in the arachnoid ; still, we should not assert, as some writers would do, that the arach- noid always remains unaffected. If it is not yet clearly proved that it has been sometimes found either injected or thickened, at least it is certain that morbid products have been found in its cavity. We have adduced cases where there were effusions in the cavity of the arachnoid either of serum or of pus; we have cited others in which cellular adhesions, similar to those of the pleura, united the two reflections of the arachnoid to each other. The lesions which may exist in the pia mater, may occupy different parts of this membrane. They are found more frequently in the convexity of the cerebral hemispheres than in any other part. When traced over this convexity, we sometimes find them extended to the two hemispheres, sometimes they are confined to one. Thus, in several of our cases, we have seen the upper surface of only one hemisphere, of a more or less bright red colour, or covered with pus, while the other was pale and free from any trace of puruleut infil- tration, or any other lesion. Frequently too, it is not the entire of the upper surface of one of the hemispheres that is the seat of this lesion (whether injections or any other). It may occupy but a more or less circumscribed portion of this surface ; and with respect to the different symptoms which may result, it is well to remark, that there are some cases, where there is found either simple redness, or purulent infiltration, precisely limited :—1st, To the anterior ex- tremity of one or other hemisphere. 2d, To its middle portion. 3d, To its posterior portion. 4th, To its lateral parts. The ante- rior part of the hemispheres has appeared to be the most frequent seat of the partial meningitis. Sept. 1S38.—0 8 66 ANDRAL'S MEDICAL CLINIC. We remember to have seen some cases wherein a bright redness existed simultaneously over the entire anterior extremity of each hemisphere ; everywhere else the pia mater remained pale. On the lower surface of the brain the same lesions presented themselves, but with more frequency, at least if we are to rely on what we have seen ourselves. There also the pia mater is seen dis- eased over a great extent of surface; sometimes, as in the convexity of the brain, some points only are found affected. In the latter case, the part where we have most frequently found purulent infil- tration, is that which is around and posterior to the commissure of the optic nerves. Some pus is also observed occasionally within the fissure of Silvius. One of our cases presented to us the rather remarkable phenomenon of purulent infiltration, which existed only on one of the halves of the pons Varolii and medulla oblongata. The pia mater covering the cerebellum, appeared to us much more rarely affected than the pia mater of the brain. The pia mater of the spinal cord presents all the changes to be found in that of the encephalon ; but from our own experience, as well as that of others, we find that the pia mater enveloping the spinal cord is much less frequently diseased, than the pia mater enveloping the brain. According to our experience also, in most of the cases wherein the pia mater surrounding the spinal cord has become the seat of purulent infiltration, this same infiltration is also found in the encephalic pia mater. On the contrary, nothing is more common than to find the latter considerably altered, whilst the other is perfectly sound. With respect to the relative frequency of the lesions of the dif- ferent parts of the encephalic pia mater itself, we find that the lesions of the pia mater of the convexity of the hemispheres, exist more frequently alone than in the lesions of the pia mater of the base. In most of the cases where we ascertained an alteration in the latter, we found it either in the ventricles, or on the convexity of the hemispheres. Diseases of the membrane lining the inner surface of the ventri- cles, have not appeared to us necessarily connected with diseases of the pia mater surrounding the brain, either at its base or convexity. We have accordingly adduced some cases in which the ventricles were filled with pus, or considerably distended by serum, without any appreciable lesion existing in the external pia mater, nor in the otber parts of the arachnoid. All possible varieties of alteration of the membranes may exist without the cerebral substance itself participating in any way with these alterations. In most of the cases reported this substance was perfectly untouched. But at other times we found it changed to- gether with the meninges. Thus, in some cases where the inflam- mation was principally seated in the part of the meninges covering the convexity of the hemispheres, we, not rarely, find the grey sub- stance of the circumvolutions injected and softened ; this substance is then raised like a pulp, when we try to separate the pia mater DISEASES OF THE ENCEPHALIC MEMBRANES. 67 from it. Sometimes we find no morbid alteration at a greater dis- tance down, and sometimes the entire medullary substance of the hemispheres presents on each slice a great number of red points, which are the divided orifices of so many vessels gorged with blood. In some cases, where the sub-arachnoid cellular tissue contained a great quantity of serum, we were struck with the species of oede- ma, of which the cerebral substance was itself the seat. On slicing this substance, and pressing it between the fingers, a serous liquid was expressed from it similar to that infiltrating the pia mater.* Every time we found in the ventricles serum sufficient to distend them perceptibly, so that their upper wall presented an evident fluctuation, we were struck with the great softening of the central white parts of the brain—namely, the septum lucidum and fornix. In one case which we have reported, and where the ventricles contained pus, another species of softening existed ; it was seated in the most superficial part of the cerebral substance which forms on the outside the wall of the lateral ventricles. In these different cases, the alteration of the nervous substance seems to be a simple complication of the lesion of the membranes. There are other cases, on the contrary, where it is the meningitis that complicates the affection of the parenchymatous substance. Thus, for instance, in certain cases of exclusive softening, which commence quite near the periphery of the brain, we find a partial meningitis, whose limits are marked by the limits of the cerebral softening. CHAPTER II. DISTURBANCES OF FUNCTION. These disturbances are of two kinds : some are referrible espe- cially to the functions of relation or animal life, and serve in a par- ticular manner to characterise the disease ; others relate to the organs of nutritive life, and though they may be less characteristic than the former, they are not however void of importance in establishing the diagnosis. We shall now pass them both in review. * This cerebral oedema is the only alteration we met in an individual, whose body we lately examined, and who, about fifty hours before death, had fallen sud- denly, deprived of consciousness and motion. He died with all the symptoms characterising a violent attack of apoplexy. This was serous apoplexy. 6S ANDRAL'S MEDICAL CLINIC. FIRST ARTICLE. DISTURBANCES IN THE FUNCTIONS OF RELATION. SECTION I. Lesions of Sensibility. These lesions have as their seat, either the membranes themselves, or the different parts which receive nerves from the cerebro-spinal axis. Similar in this respect to the different fibro-serous membranes, the meninges make known most of their alterations by a greater or less exaltation of their sensibility, whence arises pain of head, which becomes one of the most important symptoms to be considered in the history of meningitis. We shall first set about determining what is the degree of frequency of this symptom, in diseases of the meninges. Out of twenty-eight cases of affections of the cerebral meninges which we have reported, we find sixteen in which the headache existed, and twelve in which this symptom was not observed; but in these twelve, there was one (case 5) in which the patient was not minutely watched, and another (case 11) in which the delirium hav- ing existed from the commencement, the pain of head could not be complained of by the patient. In the sixteenth case, in which the pain did exist, the alterations discovered in the post mortem were as follow :— In two of these cases (cases 1, 2) the patients presented after death tumours developed primarily in the dura mater, which had compressed the nervous substance in contact with them. In two other cases (cases 3, 4) an effusion of blood existed in the great cavity of the arachnoid. In two subjects (cases 18-21) no other alteration was observed but considerable effusion of limpid serum in the cerebral ventricles. Three other subjects (cases 6,7, 9) presented nothing but redness of the meninges. Another (case 8) presented pseudo-membranous concretions depo- sited within the great arachnoid cavity. In five post mortem examinations (cases 10, 15, 22, 24, 26) we found the pia mater, whether of the convexity, or of the base, infil- trated with pus. On one of these five (cases 24) there were also found cellular adhesions intimately connecting together the two reflections of the arachnoid covering the convexity of the brain.__ This individual had been all his life tormented with headache. In only one case (case 16) we found the ventricles filled with purulent fluid. From these facts we are warranted in concluding that the pain accompanying diseases of the meninges, may exist with diseases of DISEASES OF THE ENCEPHALIC MEMBRANES. 69 these membranes widely differing from each other both in their na- ture and their seat. Let us now inquire what lesions were found in the membranes in the twelve patients who complained not of headache. In two of them (cases 10 and 16,) the pia mater was infiltrated with pus, either the portion of it extended over the convexity of the cerebral hemispheres (case 10,) or that covering the base of the brain (case 16). A sero-purulent liquid filled the ventricles in the subject of case 19. From these facts it follows, that the diseases of the membranes, during which no headache was observed, differed neither in their nature nor in their seat from those in which pain of head was one of the symptoms. The following table will show the greater or less frequency of the headache in these different cases :— Nature of the Changes. Headache. None. Accidental productions developed in the dura mater, ....2.0 Effusion of blood into the great cavity of thearachnoid,. ...2.0 Redness of the membranes,.............3.0 False membranes in the cavity of the arachnoid,......4.0 Purulent infiltration of the pia mater,.........5.2 Pus effused into the lateral ventricles,.........1.1 Serous effusion into the pia mater externally, and into the ventricles, 2 . 6 Chronic thickening of the meninges...........0.1 Out of sixty-two cases of acute inflammation of the meninges, free from any complication, described in the work of MM. Parent du Chatelet and Martinet on Arachnitis, there were fifty in which pain of head is mentioned as a predominant symptom. Of these fifty, some were cases of meningitis of the convexity, and the others me- ningitis of the base or ventricles. Of fourteen cases of acute menin- gitis free from complication, published by Dance, there were twelve in whom this symptom was observed. In the numerous cases published by Dr. Charpentier, of Valenciennes, in his work on Hydrocephalus Acutus, pain of head was noted as a more or less pre- dominant phenomenon of the disease. From this summary of the facts it follows that, in the great majority of cases, pain of head is a symptom of acute and chronic diseases of the meninges, and that it may accompany the most varied lesions of these membranes, either injection of their tissue, or the formation of membranous concretions on the free surface of the arachnoid, or purulent infiltration of the pia mater, or an effusion of pus into the ventricles, or a considerable accumulation of serum within these same ventricles. Can this headache serve to distinguish an inflammation of the meninges, and is it not also found in other diseases, which, though existing without the brain, may still give rise to several of the symp- toms which characterise acute meningitis ? To the latter, acute inflammations of the digestive tube, in particular, may be referred. Out of forty-five individuals affected with inflammation of the diges- tive tube, whether follicular or simply erythematous, whose autopsy is detailed in another part of this work, twenty-one complained of 8* 70 ANDRAL'S MEDICAL CLINIC. greater or less pain of head ; in the remaining twenty-four this symptom was not noted ; but among the latter there were seven, the precise history of whose state could not be satisfactorily ascertained. Out of thirty-one cases, whose history is described in the work of MM. Petit and Serres on Entero-mesenteric Fever, twenty-one complained of pain of head. Among thirty-six patients mentioned in Professor Bouillaud's work on fevers, headache was observed in twenty-eight. Among fifty cases reported by M. Louis, in his work on Typhoid Fever, forty-four were affected with headache. From these cases, and several others published by M. Trousseau and M. Dance (in all of which the only lesion found was in the digestive tube), it clearly follows that pain of head is a symptom observed in other instances than those wherein the nervous centres are primarily and idiopathically affected ; consequently it cannot be given as a proof of the existence of a meningeal affection. Presenting itself at the outset of several febrile affections, it indicates no doubt a distur- bance of the innervation ; but it no more established the proof of a real meningitis, than those pains of the limbs do, which are so com- mon in such cases. Is it not again to these pains, which are alto- gether nervous, and which are not connected with an inflammatory state of the organs in whose vicinity they are felt, that we should attribute several of the epigastralgia so frequent at the commence- ment of febrile diseases, and which we think are too often and too lightly attributed to a gastritis ? Still, pain of head, though joined to a crowd of different affections, may present in cases of meningitis, certain distinctive characters, indicating its connexion with an inflam- mation of the membranes of the brain. To this matter we shall now direct our attention, considering this pain of head with respect to its seat, its nature, its intensity, and duration, the time of its appearance, and its connexions with the other symptoms. We have already seen that the headache is observed with equal frequency, whatever be the seat of the meningitis. We shall now inquire whether the seat of this pain of head varies wTith that of the affection, and whether it is possible to determine exactly the point where the meninges are affected, from the part where the pain of head is felt. On reviewing our sixteen cases where there was headache, we find that in five of them the seat of the pain of head was not pointed out, or that it was stated as affecting the entire head. In the eleven other cases, it was limited to a part of the cranium, and was often circumscribed very exactly to that part. Of these eleven cases of headache thus circumscribed, there are six in which the seat of the lesion of the meninges is very precisely indicated by the seat of the pain. In the five other cases, where, as in those already considered, the pain of head was circumscribed, we find no connexion between the seat of the pain and that of the lesion. With respect to the five cases in which we no longer find the pain of head circumscribed, there is but one of them in which the lesion of the membranes was circumscribed to one point. In the four other cases, the affection of the membranes was much more general; it existed over the entire convexity of the hemispheres in DISEASES OF THE ENCEPHALIC MEMBRANES. 71 cases 3 and 11 ; the serous membrane of the ventricles was specially affected in case 20 ; and, in fine, the entire of the membrane was affected in case 24. From these facts we may conclude, that though in some cases the seat of the lesion of the membranes may be indicated by that of the pain of head, it is not always so. We have seen, in fact, some cases in which the meningitis is either much more extensive or much more limited than the seat of the headache seemed to announce. Oftentimes also the pain manifests itself at a distance from the place where the membranes are affected. Thus we have seen a simple frontal pain of head coincide sometimes with meningitis of the base, sometimes with meningitis of the ventricles. This assertion of ours is corroborated by very many cases contained in the work of MM. Parent and Martinet, as also in that of M. Dance on the acute hy- drocephalus of adults, in which there is by no means a constant connexion between the seat of the pain and that of the lesion. If we now seek what is the seat of the headache in severe fevers, we shall find that, in the great majority of cases, the pain is frontal or sub-orbital ; that in some it is more particularly felt either at the temples, the sinciput or the occiput; and that in some cases the patients cannot point out its precise seat. There are then some traits of resemblance, with respect to seat, between the headache which is the symptom of a meningitis, and that which exists in continued fever. However, we do not see in the latter case, as in the former, the headache so precisely confined to certain points of the head. The intensity of the headache appears to merit consider- able attention, when it may be an object to convert this symptom into a sign. The pain of head which accompanies severe fevers is most frequently not known by the physician, unless when he ques- tions the patient on the subject, the latter giving but a mere secon- dary attention to it. In very many cases of meningitis, on the con- trary, it is the patient who first mentions the pain of head ; and until he has become either delirious or comatose, this pain is to him one of the predominant phenomena of his disorder; it sometimes forces him even to scream aloud. It has not been found that the different degrees of the intensity of the headache depended either on the nature of the lesions of the membranes, or on their seat. We have found it as acute in cases where there was but simple injection of the pia mater, as in those where the pia mater was infiltrated with pus, or where a false membrane covered the arachnoid. With respect to the seat of the lesions, we find that, in cases where the headache was most intense, some related to meningitis of the convexity of the hemispheres, others to meningitis of the base of those hemispheres, others to inflammation of the entire membranes surrounding the nervous centres, others, again to effusions of pus or serum into the ventricles. Between these cases, and those where the pain of head waseither much weaker, or noneatall,we do not find any difference with respect to the lesions ; and in order to explain so many varieties, we are always obliged to admit individual disposi- 72 ANDRAL'S MEDICAL CLINIC. tions, which, with lesions apparently identical, produce, according to the subjects affected, phenomena of the most different kind. The nature, also, of the pain felt by patients attacked with menin- gitis is not the same in all. Some think that there is an enormous weight on their skull ; some complain of violent lancinating pain, either continued, or returning at intervals ; several fancy that a tight band compresses their forehead ; some say that their head is squeezed, as it were, in a vice. All motion applied to the head, or even to the other parts of the body, is oftentimes intolerable. We have seen some patients whose headache was increased by slight pressure made on the integuments of the cranium. We never saw, on the contrary, this pressure diminish the headache, as so often hap- pens in the cases of headache called nervous. The period when the headache appears is not the same in all cases. Most frequently, how- ever, it shows itself, from the commencement, sometimes dull at first, and gradually becomingintense; sometimes,on the contrary,attaining at once its maximum of severity. In several cases of our own, in very many published by MM. Parent and Martinet, and in nearly all those of M. Dance, the pain of head showed itself from the very commence- ment. The cases in which headache marks the commencement of the disease seem divisible into two series, according as the headache develops itself singly, without any other morbid phenomenon ac- companying it, or according as its appearance coincides with that of other symptoms. The first series includes the most numerous cases. The time during which the headache continues the only appreciable morbid phenomenon may vary from some hours to several days. When this headache thus precedes the other symptoms, there are some cases in which it seems to have nothing serious in it. It sometimes resembles mere rheumatic pain; sometimes it might be taken for neuralgia. There are some individuals who, for some time, seemed to have merely a megrim more or less violent ; the mistake was easily fallen into in those cases where, a little after the appearance of the headache, vomiting supervened. The second series includes those in which the headache, still presenting itself at the commencement, is accompanied, from the moment of its appearance, by other symptoms, whether of mere febrile commotion, or of differ- ent disturbances of innervation. There are some rare cases in which the pain of head continues with great intensity during the entire disease ; but most frequently there are developed on the part of the nervous systems more severe symptoms, which soon prevent it from being perceived or complained of by the patient. It may then be laid down that the pain of head generally exists only during the first period of meningitis. It is very uncommon to see it come on after this period. Headache is almost the only modification of sensibility observed in the ordinary cases of meningitis. In some few of the cases reported by us the cutaneous sensibility was rendered rather obtuse ; but it may be remarked, that in one of them the brain itself was the seat of considerable pressure made by a tumour deve- loped in the dura mater. There was one case, also, where the sensibility was very much exalted. From several cases published DISEASES OF THE ENCEPHALIC MEMBRANES. 73 by MM. Parent and Martinet, and also by M. Dance, we feel war- ranted in laying it down, that in the meningitis of adults, modifica- tions observed in the cutaneous sensibility may be considered as mere exceptions ; when they do exist, they are to be referred to a peculiar disposition in the subject, and not to any specific lesion. It is but rarely that pains of any importance are observed in other parts of the body besides the cranium. If we compare, with respect to their nature and their frequency, the lesions of general sensibility observed in cases of acute meningitis, with those seen in cases of typhoid fever, we shall find that in both these lesions scarcely differ either as to their nature or their frequency; so that their existence cannot serve to establish the diagnosis between the acute meningitis and severe cases of fever. We shall now terminate this consideration of the modifications of sensibility in meningitis, by inquiring in what manner the organs of the senses are disturbed in this disease, particularly those of sight and hearing. The modifications in the organ of sight were, for a long time, noted by pathologists as capa- ble of serving to characterise certain acute or chronic affections of the brain. These modifications may be classed under the three following heads :—1st. Modifications of the motions of the globe of the eye: 2d. Modifications in the state of the pupil; 3d. Modifi- cations of vision itself. The motions of the eye may be altered in several ways: sometimes they are irregular, and, as it were, convul- sive; sometimes the globe is immovable; sometimes there is stra- bismus of either one side or both. These different alterations in the movements of the eye cannot be referred to any specific lesion. They have been observed in adynamic and ataxic fevers without any appreciable lesion of the nervous centres. Strabismus, how- ever, when permanent, may be considered to possess more value as a sign of meningitis than the irregular movements of the globe of the eye, or its immobility. The state of the pupil is far from being always the same in the different cases of meningitis. Several phy- sicians consider that this opening, contracted and immoveable in the first stage of the disease, becomes dilated and immoveable, as soon as serous or purulent effusion has taken place, either around the brain or into the ventricles. This rule I do not conceive to be always exact; for with lesions precisely identical the pupils may present the most different appearance : and what is more, with lesions altogether dissimilar, these openings may present precisely the same appearance. This was also long since remarked by MM. Parent and Martinet. We find, in their work, cases of dilatation of the two pupils: first, with effusion into the two lateral ventricles; secondly, with effusion into only one ventricle ; thirdly, with mere serous or purulent infiltration around the brain (at the convexity or base); fourthly, without any of these lesions. In four cases where dilatation affected only one pupil, the effusion existed in the two ventricles. In another case, where there was also but one pupil dilated, the effusion took place in only one ventricle, that of the side opposite to the dilated pupil. With respect to contraction of the pupils, MM. Parent and Martinet cite cases where this contraction 74 ANDRAL'S MEDICAL CLINIC. 2. Dilatation of the pupils.... < 3. Contraction of the pupils< coincided with an effusion into the ventricles, and other cases in which no effusion existed. M. Guersent, the writer of the article Meningitis in the Dictionnaire de Medecin (21 vol. edit.), admits dilatation as an habitual phenomenon only in the last stage of the disease; before that period, he says that the pupils are sometimes dilated, and sometimes contracted. The result of my own observation, as also of an attentive consid- eration of the cases published by others, is, that it would be vain to attempt to connect such or such a state of the pupil with any specific morbid alteration of the membranes. Abstracting from the nature and seat of the lesion affecting the membranes, the pupils in those different affections may present the different states which follow:— 1. The pupils may preserve their natural appearance. Equal dilatation. Unequal dilatation. Dilatation of only one. Dilatation of one, and contraction of the other. Equal. Unequal. Of both. Of only one. 4. Alterations of contraction and dilatation of the pupils. But these different modifications of the pupils are also met in a number of cases, where neither the meninges nor the brain present any appreciable lesion after death. We have observed them with all their shades in individuals labouring under fever. Every one knows also how, even in a state of health, the condition of the pupil varies. And if the iris is thus subject in its movements to a thou- sand different influences—if it be under the dominion of many other modifications of the nervous centres, besides those which pathological anatomy shall ever be able to reveal to us, why place any great confidence in the signs to be deduced from the different states of the pupil in order to diagnose a meningitis ? Vision itself is, as we have said, frequently disturbed in cases of meningeal affections. In some patients it is entirely lost; in others it is perverted: thus diplopia has been observed in some cases; hallucinations have been also noted ; some persons cannot bear the rays of light on the retina. None of these alterations, however, can be said to belong peculiarly to meningitis. Very few cases have been recorded by medical men, in which the faculty of hear- ing was affected in meningitis. Our second case affords an example of deafness, in which, however, the entire lesion discovered after death was seated on the upper surface of one of the lobes of the cerebellum, and, consequently, at a considerable distance from the origin of the auditory nerves. There was then lesion of function, without any appreciable lesion of the organ destined to perform it. Here, however, some portion of the encephalic mass was found morbidly changed; whilst, in cases of typhoid fever, deafness has DISEASES OF THE ENCEPHALIC MEMBRANES. 75 been observed, where the examination after death shows this mass and its envelopes to be in the healthiest state possible, at least to all appearance. The more we study the different alterations of sensibility presented by individuals attacked by meningitis, the more satisfied we are that none of these alterations are constant, none of them necessarily con- nected with such or such a form of meningitis, and that disturbance of function is much less dependent on the membrane so affected, than on the brain itself. It is this organ that produces these disturbances, and consequently they must vary in the individual cases, according as the brain participates in, and sympathises with, the irritation of its membranes. In this way also, may be explained the infinite variability of the symptoms of pericarditis; for here too, the deter- mining cause of the symptoms is not in the pericardium, but in the heart itself. What you see on the dead body cannot always inform you what took place during life, and pathological anatomy does not certainly tell us all that is to be known with respect either to the nature, seat, or treatment of disease.* Lesions of motion.—Lesions of motion are more frequent in meningeal affections than those of sensation, but they are not more constant than the latter, and they are entirely wanting in cases where after death the same anatomical changes are found, as in the cases where these lesions have existed. Lesions of motion observed in affections of the meninges, may be divided into two great classes ; in the one, the motions continue, but they are performed in a disor- derly way ; in the other, the motions no longer exist. The first class comprises the different spasms, which are sometimes clonic, sometimes tonic. To clonic spasms we shall refer the disturbances of motion, which have been all noted in the different cases published on diseases of the meninges. Some persons present merely a state of general agit- ation ; they are constantly in motion, and rest seems to them in- supportable ; they are incessantly anxious to change their position. In others, this agitation is confined to some particular part of the body ; some patients are constantly moving their arms or legs ; in some the trunk is alternately raised and depressed ; some constantly move the head from right to left, and from left to right. In these * When either the arachnoid or pia mater, which closely invest the brain, are extensively inflamed, the function of this organ becomes inevitably disturbed by sympathetic irritation, without its parenchyma necessarily partaking of the in- flammation, or if the inflammation extend to the parenchyma, it is mostly confined to the superficial layer of the cortical substance. This is exactly the manner in which the functions of the lungs and intestines are disturbed in pleurisy, or peri- tonitis. Hence, in arachnitis or meningitis, besides headache and intense fever, we have an increase of the general sensibility, preternatural acuteness of the exter- nal senses, violent delirium and convulsions, and finally collapse, coma, and death. Extensive inflammation of the hemispheres of the brain will be characterised by a nearly similar train of symptoms. In the great majority of cases, the two dis- eases give rise to each other, and are thus combined ; it is then extremely diffi- cult, if not impossible, to discriminate between them. Cyclop, of Med., vol. i. p. 284__T. 76 ANDRAL'S MEDICAL CLINIC. cases it is the will, though irregular, that produces the motion ; there are cases, however, where the motions are involuntary ; thus, in some patients, the muscles which terminate at the flexor tendons of the fingers, are agitated by violent contractions ; hence subsultus tendinum ; several present, as a prominent symptom, a tremor which is sometimes general, and sometimes partial. Convulsions, properly so called, are among the most common phenomena accom- panying acute meningitis. These are sometimes, though very rarely, general. When partial, they are sometimes confined to the same part, at other times they affect different parts of the body suc- cessively. The parts most usually affected with convulsive motions in meningitis are, the globes of the eyes, the eye-lids, the face, the lips, and finally the extremities. Tonic spasms, as they are called, are not less frequent than clonic, in the disease now under consider- ation. Thus permanent flexion of the fore-arm on the arm is often observed. Retroversion of the head, its inclination to the right or left, are sometimes observed in cases of meningitis, as also tetanic rigidity of the neck, trunk, or extremities, trismus, &c. Under the second class, in which motion is diminished, or alto- gether destroyed, may be reckoned those numerous varieties of paralysis observed in meningitis. This paralysis may affect the muscles of the eye, of the eyelids, face, lips, or limbs : either one, or several of these, may be deprived of motion. In these different parts the paralysis may be established either slowly, or as instanta- neously as the loss of motion succeeding cerebral hemorrhage. The paralysis may supervene from the commencement, or succeed one of the forms of spasms already mentioned ; it may alternate with these spasms ; it may, in fine, co-exist with them, and we have witnessed more than once one of the upper extremities completely deprived of motion, whilst the other was more or less violently con- vulsed. There are also some cases in which the paralysis appears and disappears by turns ; a phenomenon which will not surprise us, when we have seen, that in meningitis paralysis can exist only when there is compression of the brain. Simple hyperaemia of the pia mater, slight purulent infiltration of this membrane, are capable of producing it, or, to speak more accurately, are capable of producing in the brain that modification, inappreciable after death, which gives rise to it. After having considered in a manner purely noso- logical the different lesions of motion affecting those attacked with meningitis, we shall now try to establish some relations between these lesions, and the different changes found in the meninges after death. For this purpose we shall pass in review each of the dis- turbances of loco-motive action already alluded to, first mentioning the cases only, where such disturbance existed singly at the last period of life. 1st. With respect to general agitation, none of our cases presented this symptom single. MM. Parent and Mar- tinet mention one case of it, in which the pia mater extended over the upper surface of the brain and cerebellum was infiltrated with pus. In another case mentioned by the same authors, in which this DISEASES OF THE ENCEPHALIC MEMBRANES. 77 lesion was observed, the meninges extended over the convexity of the left hemisphere of the brain were found red and thickened. 2d. Partial agitation. We have not met one instance of this symptom uncombined with other lesions of motion. MM. Parent and Martinet mention a case in which there was observed a continual balancing- of the head to the right and left: this occurred the day before the patient died. The membranes covering the upper sur- face of the cerebrum and cerebellum were opaque, very red, and thickened. The tissue of the cerebrum, cerebellum, and spinal cord were remarkably dense. These same writers mention a case in which there was a continual moving of the lower jaw, similar to that of mastication. In this the pia mater of the convexity was infiltrated with pus. 3d. Subsultus tendinum. Neither has any case occurred to us in which this symptom presented itself singly. MM. Parent and Martinet, however, record four cases, in which it was the only disturbance of the loco-motive functions. In one of these cases the meninges were red and thickened nearly throughout their entire extent. In the three others they were infiltrated with pus, either at the convexity, or towards the base ; and in two of these three cases, the ventricles contained either a serous or a puru- lent liquid, with a granulated state of the membrane lining their parietes. 4th. Trembling of the limbs. We have not met any case of this occurring singly : but very few cases of it have been mentioned by others : and where it did occur, no particular morbid change was discovered after death on which it could appear to de- pend. 5th. Convulsive movements. These are observed princi- pally in children. Five instances have been recorded in the work of MM. Parent and Martinet of their occurring in adults—in four of these there were convulsive movements of the eyelids, face, lower jaw and extremities. In three of these four there was found purulent infiltration of the meninges of the convexity of the hemi- spheres ; the fourth presented a membranous concretion, extended over the right hemisphere, and two ounces of serum in the right lateral ventricle. 6th. Grinding of the teeth. We have no account of this phenomenon having occurred singly in cases of meningitis. 7th. Permanent flexion (contracture) of the limbs. In the one case in which this was observed, we found considerable redness of the pia mater extended over the convexity of the left hemisphere of the brain, with injection of the grey substance of the circumvo- lutions of this side. In the case of a young girl mentioned by Parent and Martinet, who, during the five days previous to her death, presented permanent flexion of the two arms, there was found general inflammation of the arachnoid of the convexity. The meninges at the base were thickened, and a small quantity of pus infiltrated them towards the cerebellum. The ventricles were filled by a turbid serum. 8th. Tetanic rigidity. In a considerable number of cases where the prevailing phenomena are rigidity of the limbs, tetanic shocks of different parts of the body, tetanic curving of the trunk to the right or left, trismus, permanent retroversion of Sept. 1838.—P 9 78 ANDRAL'S MEDICAL CLINIC. the head, the lesions found after death do not differ in their nature from those just mentioned. Thus we observe different parts of the pia mater more or less injected, purulent infiltration of this mem- brane, serous or purulent effusions into the ventricles. In nineteen cases in which retroversion of the head was observed, this phenomenon coincided once with a lesion of the meninges of the convexity and base ; twice with lesion of the meninges of the convexity, base, and that of the ventricles ; three times with simple lesion of the meninges of the convexity, three times with lesion of the ventricular membrane, five times with lesion of the meninges of the base, and five times with lesion of the meninges of the base and ventricles. In fifteen cases where tetanic rigidity was one of the prevailing phenomena, whether general, or limited to some part, as to the neck, trunk, extremities, jaw, the lesions, with respect to their seat, were as follow:— Lesions of the meninges of the convexity - three times. of the base - three times. of the ventricles - three times. of the base and ventricles - four times. of the entire meninges - - twice. 9th. Paralysis. In the fifteen cases of hemiplegia already men- tioned, the following alterations were seen : in four the brain was compressed by accidental productions developed in the meninges, which compression constantly occurred on the side opposite to that of the hemiplegia, and was made from above downwards. In five of these cases the compression was confined to one of the cerebral hemispheres ; in one only (case 2) a tumour appertaining to the dura mater had compressed and wasted one of the lobes of the cere- bellum. In this last case also the paralysis was crossed, just as in those cases where the lesion was seated in the cerebral hemispheres, and nothing else was observed but simple hemiplegia, without any other modification of motility. However, before the hemiplegia was established, convulsive movements had taken place in the arm of the side opposite to that of the lesion of the cerebellum ; after- wards this limb ceased to have the power of motion ; and subse- quently the paralysis extended to the lower extremity of the same side. In the subject of our first case, the hemiplegia was established gradually without being preceded by any convulsive movement. There was in this case pressure made on one of the cerebral hemi- spheres by a fibrous vegetation of the dura mater. In our fourth case the extremities of the right side were both gradually paralysed; the fore-arm continued a considerable time flexed on the arm, but this flexion ceased at a subsequent period. Blood was found effused on the left side between the arachnoid and dura mater. In one of our cases, where a serous cyst, developed in the pia mater of the convexity, had perceptibly depressed the circumvolutions,the patient had a hemiplegia of very long standing, with atrophy of the para- lysed limbs. In six other cases, observed partly by ourselves, and DISEASES OF THE ENCEPHALIC MEMBRANES. some by MM. Parent and Martinet, this hemiplegia was seen to coincide with the presence of a thick layer of pus which filled the pia mater of the convexity of the cerebral hemispheres. Of these six cases there were three in which, though there was hemiplegia, an equal quantity of pus was effused over the two hemi- spheres, and three others, in which the pus was collected only in the hemisphere of the side opposite to that where the paralysis took place. At first sight, the proportion here seems equal, but a more attentive examination will alter it entirely ; for, in one case, at the same time that the pia mater of the convexity of the two hemispheres wasinfiltrated with pus, the substance of the brain (the lefthemisphere), on the level of, and external to, the ancyroid cavity, contained a tu- bercle, which maybe fairly considered to have caused the hemiplegia, more particularly as the latter affected the right side, and had come on progressively. In another of these cases, in addition to the puru- lent infiltration of entire pia mater, on opening the body, the inner table of the frontal bone was found a little depressed, and making slight pressure on the brain. Besides, the effusion of pus, which had taken place over the two hemispheres, extended to the base of the cranium on the side opposite to that where the paralysis had taken place. There remains then but one case in which the paralysis having occurred on the left side, the entire pia mater was found in- filtrated with pus, without any other complication, and even in this case, it was said, that towards the base the pus was more particularly accumulated on the right side. Thus in these six cases of hemiple- gia, with effusion of pus around the encephalic mass, there is not, in reality, one, in which the lesion was not greater on the side opposite to that of the paralysis. Of these fifteen cases of hemiplegia already mentioned, there re- main five in which the principal lesion existed within the ventricles, and of these five there were two, in which both the lateral ventri- cles were equally affected ; in the three others, the only, or princi- pal lesion, existed in the ventricle opposite to the side of the paralysis. In one of the above two, each lateral ventricle contained four ouncesof limpid serum ; the hemiplegia was on the right side, and seemed to have existed previous to the effusion. In one of the above five cases, the ventricles were distended by a considerable quantity of serum ; there was also at the base of the brain a pseudo- membranous exudation, and the central white parts were softened. What was remarkable in this case is, that the paralysis which exis- ted on the left side was but transient. The patient, at first, presented some rigidity of the fore-arm ; slight retroversion of the head ; convulsive movements of the eyes and strabismus ; then the right commissure of the lips was dragged ; the extremities on the left side fell into a state of paralytic relaxation, whilst those of the right side retained motion and sensation ; subsequently the mouth became straight, and the left extremities recovered their power of motion. In the fifth of these cases reported by MM. Parent and Martinet, and which they borrowed from Morgagni, the left ventri- cle was filled with pus, without there existing, either in the brain or 80 ANDRAL'S MEDICAL CLINIC. its appendages, any other appreciable lesion. During life, the power of motion was destroyed over the right side of the body. In a case reported by M. Dance, serum was found in the two ventricles ; but in the right there were but three ounces, and in the left five ; the membrane lining the parietes of these ventricles was also perceptibly thickened. A paralysis, which went on gradually increasing, affected the extremities of the right side, and the face on the same side. The extremities of the left side presented some tetanic twitches. The nature of the phenomena here seems to have been determined by the inequality of pressure made on each cerebral hemisphere, by the liquid contained in the ventricle.— Instead of hemiplegia, some cases occur in which there is paralysis of only one limb. Thus, in one case where the pia mater, traversed by tubercular granulations, was infiltrated with serum towards the convexity of the brain, the right arm, as well as the right side of the face, were the only parts affected with paralysis. In case 25, where pus infiltrated the pia mater of the convexity, and filled the ventricles, we witnessed, on the one hand, paralysis of the right arm, and on the other hand, paralysis of the left eyelid, which was depressed over the eye ; as also of the left cheek, which became passively distended at each expiration. In these two cases the brain was exposed, on both sides, to equal pressure ; yet, why do we find effects so different on the two sides of the body ? MM. Parent and Martinet relate a case where there were observed alter- nately, and within a short space of time, at first convulsive movements of the left arm, then paralysis of the right arm, then convulsions in this same right arm ; and at the same time that these convulsions exist, the right side of the face was struck with paralysis. What do we find, however, on opening the body ? Pus over the entire convexity of the brain only being more abundant on the right. In the numerous cases, where some parts, as one side of the lips, or one of the eyelids, are the only parts paralysed, we find lesion of the same nature and the same extent as in the preceding cases. The parts of the nervous centres which give origin to the nerves of the eyelids and lips, present no appreciable lesion, and the pia mater is found either injected or filled with pus, as in the cases where complete hemiplegia existed. We shall now consider those cases in which the loss of motion, instead of being confined to any particular part, is, on the contrary, general, and affects, either successively or simultaneously, the two sides of the body. In all the cases of this kind which have occur- red to us, when the paralysis of both sides came on before the final struggle, we found, on both sides of the brain, lesions corresponding to this symptom. The different facts which have now been analysed, with the view of discovering what are the lesions, which, in cases of meningitis, coincide with the different alterations in the power of motion lead us to a singular conclusion, namely, — that with similar le'sions of structure in the dead body, the most varied disturbances in the DISEASES OF THE ENCEPHALIC MEMBRANES. 81 function of motion are found to coincide ; in the greater number of cases, whether there has been convulsion or paralysis, the structural lesion after death will be the same. Thus, beyond that lesion which the scalpel points out as having its seat in the membranes of the brain, there is, in the brain itself, a modification, not recognisable by the anatomist, which is produced to be sure by the lesion of the membrane, but which variable in each individual, is the real cause of all the functional disturbances which are seen to supervene. The different disturbances in the function of motion now passed in review, may take place also in several other cases, where, the membranes being uninjured, the cerebral substance itself is altered. They may develop themselves in those diseases known under the name of fevers, the seat of which, we are so often led by the symp- toms to place in the brain. In fevers, as in acute meningitis, we often observe subsultus tendinum, convulsive motions, oftentimes partial, very seldom general trismus, tetanic affections of the trunk or extremities, permanent flexion of these same extremities, rigidity and paralysis of them, as well as that of the eyelids and lips, trem- bling of certain muscles, grinding of the teeth. But in the great majority of cases, these phenomena are less frequent, less intense, and less durable. Their existence, however, proves that this same modification, produced in the brain by the irritation of the mem- branes, may also be produced in it under the influence of other causes, and that, without there being found, after death, any appre- ciable alteration either in its substance or in the membranes which envelop it.* * M. Lallemand speaks somewhat decidedly regarding the feasibility of dis- tinguishing arachnitis from inflammation of the substance of the brain by means of the symptoms connected with lesion of the functions of the muscular sys- tem ; after premising that these symptoms present themselves under two opposite forms, with increase or diminution of action, with phenomena of irritation or of prostration, and having stated that both forms of action are common to arachnitis and encephalitis, he then says—" You see, by these oases, that the spasmodic contractions of the muscles may me produced by an arachnitis, and we shall see presently that attacks of epilepsy, contractions of the limbs, convulsive move- ments, subsultus tendinum, are the ordinary symptoms of affections of this mem- brane. You must not, however infer from this, that the arachnoid has a direct influence on the muscles. When this membrane is inflamed, the brain is irritated by the vicinity of the inflammation, its functions are exalted, and consequently those of the nervous system which are dependent on it, therefore also those of the muscular system; thence, convulsive movements, &c.: but as the tissue of the brain is not touched, these spasmodic symptoms are neither accompanied nor followed by paralysis. Thus, though they are sometimes observed at the commencement of inflammations of the brain, they are not sufficient to character- ise this disease. But you will remark, that at this period the brain is as yet only irritated as in cases of arachnitis, its tissue not being yet altered; it is not surprising, therefore, that the symptoms should be the same. However, it would be possible even now to distinguish them by this means: when they are produced by the affection of the arachnoid, they usually manifest themselves on the two sides of the body, whilst, when they depend on inflammation of the brain, they most frequently affect only on one side. Besides, they cannot be confounded long: for in the latter case they are soon accompanied by symptoms of paralysis, and very frequently even there is observed from the commencement 9* 82 ANDRAL'S MEDICAL CLINIC. ARTICLE III. Lesions of the Intellect. The intellectual faculties were found altered in the great majority of the cases which we have reported, as may be seen by referring to them. In fifty-four cases of acute meningitis affecting adults, reported by MM. Parent and Martinet, there were only two in which the intellect was not disturbed ; whence, we may lay it down that lesion of the intellect is a much more constant phenomenon in acute meningitis, than that either of sensation or motion. Such lesion may present itself under two different forms in this disease, either under the form of delirium or that of coma. The delirium may present the greatest varieties with respect to its nature ; in some it is very violent, accompanied with loud cries, and a great development of muscular strength. In others, on the contrary, it is of a silent description, and the patients appear very much prostrated in strength. Sometimes one single idea engages the mind of the patient; sometimes ideas of the most heterogeneous description occupy his thoughts. In some, this disturbance of intellect attains its highest degree from the very commencement; in others it comes on gradually and insensibly. On reviewing, in each case, the numerous varieties of form which the delirium presented, we might arrive at this important conclusion ;—that no single one of these various forms characterises meningitis, that there is not one of them which may not be found in the different cerebral irritations which are purely sympathetic, and unaccompanied with the most singular mixture of paralysis and spasmodic phenomena." Lettre ii, p. 251; and at p. 277, he says :—" To sum up, the affections of the brain, and those of the arachnoid by their influence on the functions of the brain, manifest themselves externally by the lesion of the same functions, that is to say, by sym- toms which are Telated to the perception of the impressions made by external agents, to intelligence, and to voluntary motion. The symptoms of inflamma- tion of the brain present two characters entirely opposite ; those of irritation, and those of collapse. On the one hand, exaltation of the intellectual faculties, headache, sensibility of the retina, contraction of the pupil, pains of the limbs, continued or intermittent contraction of the muscles : on the other hand, diminu- tion of intelligence, stupor, somnolence, deafness, loss of sight and of speech, paralysis of the muscles, insensibility of the skin. The former set of symptoms are also observed in inflammation of the arachnoid, and the second in apoplexy. But it is only in inflammation of the brain that they are found combined, because in the former case there is irritation of the brain without alteration of its tissue; in the second there is, from the first, alteration without irritation : it is only in inflammation of the brain that there can be successively irritation and disorganisa- tion. When the paralysis precedes the spasmodic symptoms, it is, that the alteration of tissue precedes the inflammation ; that is to say, there is from the first effusion of blood. Finally, when the spasmodic symptoms are wanting, the slow and progressive course of the paralysis will easily render it distinguish- able from that which is produced by apoplexy. Thus then in inflammation of the arachnoid we have spasmodic symptoms without paralysis,- in apoplexy, sud- den paralysis, without spasmodic symptoms,- in inflammation of the brain, spasmo- dic symptoms, slow and progressive paralysis, unequal and intermitting course.'1'' DISEASES OF THE ENCEPHALIC MEMBRANES. 83 any structural alteration of the membranes appreciable on the dead body. When once the delirium has developed itself, it may not cease presenting merely alternations of exacerbation and remission ; it may also be only transitory. There are some patients in whom this disturbance of the intellectual faculties is but of very short dura- tion ; then, at the end of a period, more or less long, it returns ; the intermissions become more and more short, and at last, the dis- turbance becomes continued. In some, the delirium commences only at night, and the clearness of the intellect during the day seems, at first, to exclude the idea of a meningitis altogether. In some, a delirium of several days' duration suddenly disappears a little before death, when the other symptoms become more aggra- vated. Wherefore, when it is attempted to distinguish the delirium produced by meningitis from the delirium produced by sympathetic irritation of the brain, it is wrong to lay it down that the latter only can be intermittent, as numerous cases prove, beyond all doubt, that delirium arising from meningitis may be accompanied with perfectly lucid intervals. The period of the disease at which the delirium appears, is far from being the same in every case. Very rarely this phenomenon marks the outset of the malady ; so that, in the midst of health, when delirium does suddenly come on, it is not at all probable that it is dependent on meningitis. In the great majority of cases, pain of head precedes it; and oftentimes six, eight, twelve, and even fifteen and twenty days pass on between the period at which the pain of head presents itself, and that at which the intellect commences to be disturbed. Out of forty cases of acute meningitis which fell either under our own view, or under that of others, in which we were certain on the one side of the precise time of the invasion of the disease, and on the other hand of the moment at which the intellect began to be disturbed, we found the delirium to develop itself 1st day - 3 times. 7th day - 4 times. 13th day - 4 times, 2d ■ 1 8th - 6 14th - 1 3d ■ 3 9th - 2 15th - 2 4th ■ 3 10th - 0 16th - 1 5th ■ 3 11th - 0 20th - 2 6th • 3 12th - 1 24th - 1 Since, with very few exceptions, delirium presented itself as a constant phenomenon in acute meningitis, we must conclude that it may be produced in this disease, whatever be the nature of the lesion of which the membranes are the seat. All the lesions, in fact, observed in our several individual eases, were accompanied with delirium. It is certainly curious to see a mere sanguineous congestion of the pia mater, even in cases where it is partial, a little pus infiltrating its meshes, produce the most serious disturbance in the intellects ; whilst a much more deeply seated alteration of the brain, an extensive softening for instance, often exists without giving rise to the slightest disturbance of the intellectual faculties. Is it, as has been said, because the irritation of the membranes re- 84 ANDRAL'S MEDICAL CLINIC. acts principally on the most superficial parts of the cerebral circum- volutions, and that the intellect is chiefly seated there ?* We shall next consider, whether for the production of delirium it is a matter of indifference what part of the meninges be affected. In this inquiry we can take into account those cases only in which the delirium continued to the end, single, and without being fol- lowed by coma. We have met but twenty-eight cases of this kind occurring either in our own experience, or recorded by others. In these twenty-eight cases, the lesion existed On the upper surface of the two cerebral hemispheres - - 14 times. On the upper Surface of only one hemisphere - - - 15 On the upper surface of the two hemispheres, and at the base 3 On the upper surface of the two hemispheres, at the base, and in the ventricles - - - - - -- - - 4 At the base alone ---------0 In the ventricles alone --------2 Thus in these cases there are nineteen in which the lesion was limited to the convexity of the hemispheres, and only two in which the delirium persisted until death, without there being a lesion of the meninges extended over the upper surface of the brain. Instead of delirium, patients labouring under acute meningitis may present a state of coma, which sometimes exists from the com- mencement of the disease, and sometimes comes on only after delirium. This second case is much more frequent than tbe first, at least in adults. When a patient dies in the midst of a state of coma, the lesions found in the meninges differ neither in their nature nor seat from those found in cases where life is terminated in the midst of a state of delirium. But then are these lesions different as to their seat? To solve this question, we shall take a review of the facts as they have been observed. Out of sixty-one cases, in which death supervened in the midst of a comatose state, which existed either for several days with or * On the subject of delirium, as connected with arachnitis, Lallemand makes the following remarks :—" Delirium is in general regarded as a symptom of in- flammation of the brain; its absence might induce one to doubt of the inflam- matory nature of softening of the brain. But it is, on the contrary, a stronger reason for this opinion; it will be no difficult matter satisfactorily to prove that delirium is never observed in inflammations of the brain which are exempt from complication, that this symptom belongs specially to inflammations of the arach- noid, that persons have been led into error by the very numerous cases in which the affection of the arachnoid preceded that of the brain. I admit that it seemed natural to attribute the delirium to inflammation of the brain, rather than to that of the arachnoid; but still an error was committed. Do not, however, suppose that I would make the arachnoid the seat of the delirium; every symp- tom is the alteration of a function, and cannot be produced but by the orrmed by the optic thalamus, the corpus striatum, and all the other parts situate on the level of these two bodies. Of the nervous mass above the ventricles there remained only that which, being anterior to the corpus striatum, forms its anterior wall. Numerous tubercles were in the two lungs, and several ulcerations appeared on the sur- face of the small intestine. There was a perforation in the ileum, whence the peritonitis which terminated the life of the patient. Remarks.—The lesion, discovered in this case, began from ex- ternal violence, twenty-five yea.rs before the period when it came under our inspection. The atrophy of the brain was not probable here the primitive alteration : it succeeded to other changes of an inflammatory nature which supervened immediately after the fall. The perfect preservation of the intellect up to the last moment is certainly a remarkable circumstance in a case where so great a por- tion of the brain had for a long time been moved. In a similar case, quoted by M. Breschet, of a child four years old, the mind was, on the contrary, very much altered ; the child was DISEASES OF THE BRAIN. 255 completely idiotic ; it was dumb, though not deaf; and could not sustain itself on its feet. It more frequently happens that we find atrophy of only a smaller portion of the nervous mass above the ventricles. In this case it is most commonly in one of the anterior lobes that the defect of deve- lopment exists. Separate atrophy of this lobe has been seen at all ages, from commencing infancy to advanced old age. The follow- ing is an example of it, observed by us on an individual seventy-one years old :— Case 2—Hemiplegia of a long standing—Obtuse state of the intellect, great difficulty in speaking—Atrophy of the anterior lobe of the left hemisphere. A man, seventy-one years of age, entered La Pitii in a complete state of childishness. We could obtain no information regarding his previous history. We ascertained in him the existence of a complete paralysis both of motion and sensation of the right side of the body ; he stammered out some unintelligible words. This man gradually became weak, and died about a month after his admission. During the last eight days of his life we observed that he coughed, that his respiration was embarrassed, and his tongue had become dry. Post mortem.—The left hemisphere in its anterior fourth was replaced by a cyst with transparent parietes, filled with limpid serum ; one very thin layer of nervous substance separates it from the corpus striatum ; thus it does not immediately form the wall of the ventricle. The left lung was in the state of red hepatisation throughout its entire extent. Remarks.—There was hemiplegia in this case, though the lesion had attacked only the anterior part of hemisphere, and the intellect was disturbed, though the atrophy was much less considerable than in the subject of the first case, where it remained sound. M. Breschet has published the remarkable case of a girl, fifteen years of age, in whom the two anterior lobes were wanting. At the bottom of, and behind, the membranous pouch which replaced them, the two corpus striata were seen exposed. The head was very well formed. This girl was plunged into a complete state of idiocy ; it was necessary to dress her and feed her ; she was averse to walk, though she had the power of moving all her limbs vvith ease, and with equal facility ; she was usually sitting, and remained so for entire days, alternately inclining the head from one shoulder to the other ; vision was entire ; the most perfect indifference existed for the quality of odours. Here was a case where atrophy of the two anterior lobes did not bring on paralysis, probably speaking. Neither did this paralysis exist in two other subjects, who were still younger, for a knowledge of which we are also indebted to M. Breschet. In one of these cases the individual, nineteen months old, was able to move his limbs with ease, only there was observed in him 256 ANDRAL'S MEDICAL CLINIC. an almost continual flexion of the trunk backward. This child was deprived of sight: after having remained for about four months in this state of opisthotonos, he was seized with convulsions, of which he died. All the mass of the hemispheres situated above the ventricles was less developed than usual; anteriorly it was completely want- ing on both sides, and in its place all that was found were the meninges raised by a great quantity of serum. The head was in every other respect well formed, only it was somewhat large. In the other case the child, twenty-two months old, also had the cranium well formed ; he was affected with strabismus ; motion and sensation were complete. This child died of a gastro-enteritis. The same alteration of the brain was found in him as in the preceding. Besides these cases, in which the nervous substance was replaced by serum in greater or less abundance, other cases may be cited in which this serum no longer existed, and where all that was observed was a greater smallness in the different parts of one of the hemi- spheres, and particularly of the convolutions. This species of atro- phy seemed to us sometimes primitive and congenital, sometimes consecutive to, and developed after a number of diseases. There are some cases of this kind published by M. Casauvieilh, in his interesting paper on cerebral agency.* The persons whose cases he cites, aged from twenty-seven to sixty-eight years, were all affected for a great number of years back with lesions of motion on one side of the body (hemiplegia, simple or with contraction), and their intellect was more or less obtuse. The extremities opposite to the atrophied hemisphere had in their different dimensions less development than the others. Instead of atrophy affecting but one of its hemispheres, the brain may present, in both sides at one and the same time, in several of its parts, a deficient development considerable enough seriously to interfere with its functions. This general atrophy of the brain ex- isted in a remarkable manner in an epileptic patient, whose case is recorded by M. Calmeil.t In the cases recorded by M. Casauvieilh, the lesion of motion was more ardent than that of intellect. The same also occurred in the following case, seen by us some years since at La ChariU. Case 3.—Forty-seven years of age—Hemiplegia of long standing—Mind a Cttle weakened—Atrophy of one hemisphere, with hardening of its substance—Death by pneumonia. A man, forty-seven years of age, was paralysed in the entire left side of the body, when he was admitted into La ChariU under the care of M. Lerminier. This paralysis had existed all his life : he had not, at least, any recollection of when it commenced ; all he said was, that in his childhood he could not use his extremities of the * Archives Generates de Medicine. f Journal Hebdomadaire de Medicine, torn. i. p. 225. DISEASES OF THE BRAIN. 257 left side. There was no trace of contraction ; the limbs deprived of motion were manifestly thinner, but shorter than those of the opposite side ; the skin covering them had preserved all its sensi- bility. The intellect appeared to be a little weakened ; he possessed, however, his reason, and could join in a connected conversation; the functions of the life of nutrition were duly performed. This man was seized suddenly with symptoms of acute pneumonia, of which he died. Post mortem.—The cranium was considerably depressed over all the right side. We had not observed this depression during life. On the right, also, it has less extent in its different diameters, and its walls are manifestly thicker than on the left. The meninges present nothingremarkable; the two hemispheres are different in size the right evidently smaller than the left. This greater smallness evidently depends on the shrivelling which the middle lobe had undergone, the tissue of which was, at the same time, remarkably dense. The optic thalamus and corpus striatum of the right side are much smaller than the same parts on the opposite side. The right lateral ventricle contains more serum than the other, and is also larger. The left lung is in a state of red hepatisation, in the two-thirds, at least, of its extent. Remarks.—Was the change, of which the right hemisphere was the seat, in this subject congenital; it may be supposed so. It had left mind and sensation almost entire ; motion alone was seriously compromised, and, in the paralysed limbs nutrition was less active, as was proved by the commencement of atrophy of these limbs. What was the cause of this atrophy ? Was it merely the want of ex- ercise on the part of the muscles ? Was it a less action of the brain on the nutrition of the parts, and if this fact may serve to prove the influence exercised on nutrition by the nervous system ? In fine, the same cause which in the foetus had produced in one of the sides of the brain a suspension of growth, had it interfered, at the same time, with the evolution of the limbs opposite to the atrophied hemisphere ? There was here but simple paralysis ; in other cases, where the lesion was precisely similar, the limbs deprived of voluntary motion were, at the same time, contracted. The same phenomena were presented by some of the cases of M. Casauvieilh. We saw this exist, also, in the patient of Bicetre whose case has been already detailed. This may also be seen in the following case recorded by M. Boulanger. A child, two years old, experienced a constantly increasing diffi- culty in moving the extremities of the right side ; there supervened a state of permanent contraction of these limbs, and particularly of the upper extremity of the right side. The right forearm very much con- tracted on the arm, and it cannot be extended without causing pain. He complains of a fixed pain in the left parietal region ; the intel- lectual faculties are sound; he speaks very well, likes to play and converse. He arrived at the age of four years, and then died of pneumonia. Oct. 1838.—^ 24 258 ANDRAL'S MEDICAL CLINIC. On opening the body, the anterior lobe of the left hemisphere was found as it were depressed by a furrow which was filed by a serous infiltration of the pia mater (these are the author's own words). The convolutions were pressed inwards, changed to a black and yellowish colour ; the septum lucidum did not exist. It is to be remarked here, that the alteration of the right hemi- sphere did not consist in mere atrophy of its substance ; the latter in those parts where it had less volume, presented at the same time a remarkable change of consistence. Was there then a compression and accumulation of the molecules of the nervous tissue, rather than a real lessening of their number ; and was the atrophy but apparent? The third case of M. Casauvieilh presents, in this respect, a similar phenomenon, that is, coincidence of smaller volume and greater density ; but in several other cases of his, we see these two lesions no longer go together ; the consistence is normal, and yet the nervous substance does not occupy the space it should ordinarily fill. When the atrophy is still more inconsiderable or more general than in our case and in those of MM. Casauvieilh and Boulanger, the intellect becomes in its turn more seriously disturbed ; it is usually abolished, and the individuals are born idiots, or become so. The following case is in support of this opinion :— Case 4.—Seven years—Idiocy—Epileptic convulsions—Pulmonary tubercles. In the year 1821, there was in the Hopital des Enfans, under the care of M. Jadelot, a little girl seven years old, who, from birth, had not given the least evidence of intellect. The two lower extremi- ties were much more slender than might have been expected from her age ; no voluntary motion could be imparted to them by the patient, who remained constantly lying down ; the upper extremity of the right side was habitually the seat of strong contraction. This child did not speak, and it presented all the traits of complete idiocy ; from time to time it was seized with convulsive move- ments, which bore considerable resemblance, to the convulsions of epilepsy ; she died of pulmonary phthisis. Post mortem.—The cranium had, more particularly anteriorly, much smaller dimensions that what is usually seen at the age of this individual. A copious serous liquid infiltrated the pia mater over the entire convexity of the hemispheres ; this liquid had put an interval of several lines between the arachnoid and brain. The convolutions, on the right as well as on the left, but more ante- riorly than posteriorly, were remarkable for their deficient develop- ment, and at the same time for their diminished number. They were shrivelled, and, as it were, decayed ; the result of this was, that on the different points of their convexity, the cerebral hemispheres did not present a surface which had every where the same level ; it was on the contrary singularly uneven : it presented a series of elevations, few in number, and of depressions much more numerous. In most of the depressions the nervous tissue was very dense ; it DISEASES OF THE BRAIN. 259 had even in some parts a cartilaginous consistence. The lateral ventricles were very large and filled with a great quantity of limpid serum. The optic thalami and corpora striata were very small; it was particularly on the left that this defect of development was remarkable ; and on this side the optic thalamus was all unequal and wrinkled. Remarks.—This case presents us, with respect to motion, the same disturbances as the preceding ; to this is added a very serious deficiency of the intellect, which is amply accounted for by the greater degree of cerebral atrophy, and its existence in both hemi- spheres. The contraction of the right upper extremity corresponds with the greater atrophy of the optic thalamus and corpora striatum on the left than on the right. In these cases of atrophy, as well as in the cases of hypertrophy previously quoted, the cere- bellum does not follow the condition of the brain. No matter how perceptible the modifications in the size of the latter ; the other is not influenced by it, at least in the generality of cases ; for among those of M. Casauvieilh, there is one where we see the hemisphere of the cerebellum participate in the atrophy affecting the cerebral hemisphere of its side. In the case now cited, the lateral ventricles were remarkable for their extreme size, which contrasts with their diminution or oblitera- tion, so perceptible in the cases of hypertrophy above detailed. SIXTH ORDER. OBSERVATIONS ON CANCER OP THE BRAIN. This affection, characterised by the existence, within the nervous substance, of new products known by the name of schirrus and encephaloid matter, is rather rare. The remarks which we shall present on it are founded on the analysis of forty-three cases, some of which occurred in our practice, whilst the others are scattered through different medical works. In these forty-three cases, the cancer had not always for its seat the cerebral hemispheres themselves ; thirty-one times it affected these hemispheres ; three times the pituitary gland ; five times the cerebellum, once the pons varolii; and three times the spinal marrow. The size of the cancerous masses developed in the nervous centres is far from being always the same ; there are some cases where one entire hemisphere was transformed into a cancer; there are others where the accidental product scarcely equals the size of a nut. This number is equally variable ; sometimes there is but one ; sometimes several are found, which occupy different points of the encephalon. 260 ANDRAL'S MEDICAL CLINIC. Around these cancerous masses the nervous substance is far from presenting an always identical appearance. There are some cases where it exhibits all the conditions of its normal state ; there are others where it is altered; either simply injected in different degrees, or hardened and more frequently softened. When the cancer affects the periphery of the brain, it may attack the meninges and destroy them ; it may again extend its ravages to the bony structure itself. Cases have been seen where it com- pletely destroyed the temporal and frontal bones ; others have been seen, where, after having perforated the cribriform plate of the ethmoid bone, it penetrated into the nasal fossae, and filled the different sinuses which communicate with these cavities. In one case the cancer, developed on the side of the lower surface of the brain, escaped from the cranium, sending ramifications through the foramina of its base. When the cancer is situated so as to touch the nerves, it seldom leaves them entire ; sometimes they also undergo the cancerous degeneration ; sometimes they are compressed or destroyed by the tumour which surrounds them. Among the forty-three cases included in our analysis, there were ten in which the cancer, of which the nervous centres were the seat, had also attacked other organs. In none of these ten cases does the brain appear to have been the primary seat of the disease, and different parts must already have been attacked by it, so that the nervous centres may be affected in their turn. Sometimes also the brain becomes cancerous, only after a cancer had been removed from some part. There was a remarkable case of this nature lately in the wards of La ChariU, in the words of MM. Boyer and Roux :— A man received a blow on the testicle ; this organ remained tume- fied and painful, and rapidly underwent the cancerous degeneration; it was removed. Up to the moment of the operation all the other organs appeared sound. The diseased testicle had not been long removed, when, all at once, this man, who had hitherto enjoyed a tolerable good state of health, wasted away rapidly ; he died, and on opening the body, enormous cancerous masses were found in all the lym- phatic ganglia of the mesentery, in the liver, in the spleen, in the lungs, and finally in the brain. Thus, in this case, external violence acts as a purely occasional cause to develop in the part accidentally irritated, a lesion to which the economy was predisposed ; without this predisposition it would not have produced it. Immediately cancers sprout up from all parts ; there is no longer a necessity, in order to give rise to them, for an external irritation, similar to that which had acted on the testicle ; but, what is remarkable, this diathesis does not appear, or at least, the symptoms do not betray it to us, until the organ is removed, in which the cause of the cancer seemed to be enclosed. The causes under the influence of which the cancer of the brain is developed are not better known than those which produce it in DISEASES OF THE BRAIN. 261 the other parts of the body. Here, as elsewhere, a pre-disposition must be admitted, without which the occasional causes are ineffi- cient. These latter themselves are not appreciable, except in a very small number of cases. Thus, out of forty-three cases there were but two in which the cancer of the brain succeeded to external vio- lence, to which the cranium had been subjected. In none of these cases did it develop itself after an acute disease of the brain, or of its envelopes. Cancer of the brain has been observed at the most different periods, from the age of two years up to that of seventy-seven. The follow- ing is what our forty-three cases present to us in this regard. Before the age of twenty years, eight cases of cancer of the ence- phalon were observed, of which 2 cases were at - 2 years. 1 case was at - 11 years. 1 - - - - 3 1 ... 14 1 - - - - 4 1 ... 17 1 - - - - 7 From twenty to thirty years of age we know of but two cases, one of which was of a subject aged twenty-one years of age, and the other an individual aged twenty-nine years. From thirty to forty years of age we find eight cases distributed, as follows: 2 cases at - - 33 years. 2 cases at - - 37 years. 1 - - - - 34 2 - - - - 38 1 - ... 36 From forty to fifty years of age we find eleven cases distributed, as follows: 1 case at - - 40 years. 3 cases at - - 47 years. 1 - - - - 41 2 - - - - 48 3 - - - - 45 1 - - - - 50 From fifty to sixty years of age we find nine cases distributed, as follows: 1 case at - - 51 years. 1 case at - - 57 years. 3 - - - - 52 3 - - - - 58 1 - - - -55 From sixty to eighty years of age we find five cases distributed, as follows: 1 case at - - 62 years. 1 case at - - 71 years. 1----64 l _ - - - 77 1 - - - - 66 In the same manner as with all the other accidental products de- veloped in the brain, cancer does not reveal its presence by any characteristic symptoms. According to its situation, size, state of the nervous substance around it, and in a word, according to the manner (and that is altogether vital) in which the brain is affected by its presence, this morbid product is accompanied by different phenomena, and it is much less by their own nature than by their 262 ANDRAL'S MEDICAL CLINIC. mode of appearance and connexion, and by the whole of the cir- cumstances of the disease, that we can establish a diagnosis. These phenomena may regard the intellect, motion, sensation, and the different acts of organic life. The mental disturbances are by no means constant: far from it, in the greater number of cases observed up to the present time the intellect has remained totally entire. In others, it is disturbed only in the latter period of the disease. There are cases also where it is but at intervals more or less remote that the intellectual faculties become impaired ; the individuals affected present from time to time either an obtuse state of the mind, or a greater or less loss of memory, or a true delirium. In fine, some of the individuals, in whose brain cancer has been discovered, have been affected vvith insanity. Neither are the lesions of motion more constant than those of intellect; they have been found absent in more than one case. When they do exist, which is the most common event, they generally consist in a paralysis which comes on gradually. Sometimes this paralysis is partial, simple hemiplegia, or else paraplegia. This latter species of paralysis took place in a remarkable case cited by M. Esquirol, in which each anterior extremity of both hemispheres was occupied by a cancerous mass. This paralysis may be simple, or complicated with contractions, either continually, or at intervals. In several, cases convulsive movements, sometimes partial, some- times general, come on at intervals. Finally, in more than one case the existence of attacks of epilepsy has coincided with the development of a cancer in different points of the encephalon. Thus the further we advance, the more we see epilepsy show itself in connexion with lesions of the most different kind. The lesions of sensation are as variable as those of motion and intellect. Thus the pain of head, though frequent, is not observed in all cases ; it presents the greatest differences with respect to its intensity, sometimes being very slight, and being mentioned by the patient only when he is questioned on the subject; sometimes so intense, that it constitutes the predominant symptom of the disease. Its nature varies as its intensity : it is far from always having that lancinating character which is laid down as connecting itself par- ticularly with cancerous affections. This kind of pain has been rarely remarked in the different cases of cancer of the brain published up to this day. If we consider this pain with respect to its seat, we shall find that in certain cases it is general, and by no means indicates the point of the brain which is the seat of the lesion ; whilst in other cases it exists only on one side, and is then of more value as a diagnostic sign ; but if in this case it is explicit regarding the seat of the affec- tion, can it reveal its nature ? Certainly not; for it may be produced by several other lesions, and, among them, by a softening, as we have DISEASES OF THE BRAIN. 263 seen. Is it then by its particular character, or by its intensity, that we shall distinguish the pain of cerebral cancer from that which ac- companies other affections of the encephalon ? We never can attain more than mere probability on this subject. The pain of cancer of the brain simulates in some cases a neuralgia by the manner in which it radiates, from always the same point, towards other parts of the cranium. As a neuralgia, it may develop itself under an intermittent form, without, however, there being any regularity in its returns. Like certain pains called nervous, we have seen it diminish by greater or less pressure made on the points which it occupies. Bleedings, which have no influence on the or- ganic affection of which it is a symptom,£may, however, diminish it, or even make it disappear for a time. Amongst the cases that have been published, there are some in which we see the pain return, or become exasperated at the return of each menstrual* period, and then cease or diminish when once the discharge is established. In all these cases, however, the organic lesion continues the same; but around it the state of the nervous substance is continually changing. Pain more especially felt in the head in cancer of the brain may exist also in other parts. Thus, in certain cases, individuals labour- ing under this affection have experienced in the trunk and extre- mities pains more or less acute, which simulated very closely rheu- matic or nervous pains. Others have presented an extraordinary exaltation of the cutaneous sensibility; the skin could not be touched without a most painful impression being felt, whilst at other times, on the contrary, the skin lost all sensibility. Sometimes, in fine, an insupportable itching tormented the patient. Thus from one and the same lesion, the brain, in each individual, sends to the organs an infinite diversity of its inpressions, which are the reflexion of what passes in it. The functions of the organs of the senses have been changed in some cases, though the nerves appertaining to them were not com- prised in the cancerous degeneration. Nothing can be more re- markable in this respect than a case published in a periodical re- garding a girl seventeen years of age, who lost successively the use of all her senses, and in whom motion was at the same time destroyed, whilst in the midst of all this disturbance the intellect remained sound. In three cases of cancer of the pituitary gland, which have been published, there was amaurosis ; but this circumstance depended no doubt on the participation of the optic nerves in the disease. In one of these cases, the first symptom had been a gradual weakening of vision accompanied by acute pains in the forehead. * No doubt at each menstrual period the modification experienced by the uterus is felt through all parts of the system. Numerous facts might justify this asser- tion : here is a striking example of it:—We know a lady in whom, at the return of the menses, the skin of one of her arms, which has the mark of a cautery, reddens and becomes the seat of very severe itching. 264 ANDRAL'S MEDICAL CLINIC. For three years nothing else was observed ; there then came on stupor, more and more profound, in which the patient died. With respect to the life of nutrition, nothing particular is ob- served. In some individuals, obstinate vomiting has been observed, a phenomenon which is found in a certain number of cerebral affec- tions, acute or chronic, very different from each other. The pale yellow tint of the face is not here more constant than in other cancerous diseases. Nothing is more variable than the duration of cerebral cancer. At times some months only elapse between the appearance of the first symptoms and death ; sometimes these symptoms are prolonged for several years before the fatal termination. The latter may come on in two ways: either the signs of an acute encephalitis are evinced, and the individuals die either of coma, or of convulsions, or else they waste away gradually ; their strength is lost, all their functions be- come deteriorated ; intervening inflammations attack the lung, or the primae vise ; eschars form on the skin, and death is the result of all these combined causes of destruction. The following cases collected by ourselves, may be added to those which have been already published. Case 1.—Pain of the head of long standing limited to one side of the cranium— Hemiplegia—Intermitting symptoms of cerebral congestion—Cancer in the right hemisphere. A man, fifty-eight years of age, of a strong constitution, felt for the first time, fifteen years since, an acute pain which spread from the right temple over the entire right side of the head and face. This pain remained during six weeks. For some years following it returned several times without having any thing regular either in its returns or in its duration. It appeared two months ago with more violence than ever, and it soon became sufficiently intense to compel the patient to give up his occupation. A blister applied to the temple quieted him for some time. Having entered La ChariU 15th November 1821, the patient was in the following state:— Countenance yellow, dejected ; intellectual and sensorial faculties sound, except that there existed from time to time a temporary diplopia ; muscular strength preserved ; violent pains in the right sideof the head, extending sometimes to the corresponding side of the face, becoming worse at intervals, so as to make the patient scream ; sometimes lancinating, sometimes resembling a flame of fire passing through the head ; right eye habitually weeping ; pulse strong and slow ; digestion and respiration natural. (Anodynes to the right temple, mustard pediluvia, blister to the nape of the neck.) Though the state of the patient appeared nearly the same during the night the pain became insufferable. The 21st November, the patient having got out of the bed felt his legs bend under him, and he fell. The next day, 22d, his eyes were closed ; he answered no questions. (Thirty leeches to anus, sinapisms, and purgative enema.) The 23d, stupor; answers questions ; right upper eyelid para- DISEASES OF THE BRATN. 265 lysed ; right commissure of the lips drawn up ; no voluntary move- ment in the extremities of the left side ; no deviation of the tongue ; preservation of the sensibility ; pain of head much less. (Arnica, senna enema.) From this period the preceding symptoms continued ; the patient became rapidly debilitated ; his features were altered ; his counte- nance assumed a still more yellow tint; his pulse was soft, accele- rated, and presented, besides, from one day to another, the greatest variations ; the tongue was alternately brown and vermilion colour, dry and moist ; several times the patient was found plunged into a profound coma, with a tracheal rattle, which seemed to announce his approachingdissolution. The day after, this rattle no longer exist- ed or was much less, and the intellect was re-established ; the patient no longer complained of head; he was in a state of apathy, or as it were indifferent to his situation ; he resembled a person who had just got out of a profound sleep ; his eye was closed and void of expression (blisters to the chest and leg, decoction of polygala, laxa- tives) ; the adynamic state went on ; the stupor and rattle became continual ; the extremities cold, and the patient sank. Post mortem.—The sub-arachnoid cellular tissue was infiltrated with a moderate quantity of serum. Viewed externally the convo- lutions of the right hemisphere seemed flattened. When cut in thin slices, to the level of the corpus callosum, the brain presented nothing remarkable, except that there flowed a considerable quantity of serum from each lateral ventricle. Anterior to the optic thalamus of the right side was a small softening of the size of a quarter of a dollar ; there, the cerebral substance, slightly yellowish, was re- duced to a diffluent pulp, but outside the right optic thalamus and the corresponding corpus striatum, there existed another species of alteration. For the extent of four fingers' breadth in length, and of two or three in breadth, there appeared a surface of a reddish grey, wrinkled, uneven appearance, presenting altogether the aspect of certain fungous growths of the dura mater. On cutting into this part, the scalpel encountered a resistance similar to that which scirrhous growths of the stomach and liver oppose to it. Here there was found a tissue as it were areolated, of a bluish white, half transparent, very hard, and marked here and there with small cavi- ties full of a liquid similar in appearance to apple-jelly (scirrhus in the state of crudity or softening). In other points there was seen a tissue of a dirty white colour of considerable consistence, and tra- versed by reddish lines crossing each other in different directions. In other points, in fine, nothing was found but a sort of reddish inorganic mass. This alteration prevailed, in depth, from the level of the optic thalamus to near the base of the skull. The cerebral substance, healthy around it, was connected to it by continuity of tissue. Parietes of the left ventricle a little hypertrophied. Remarks.—We see in this case a violent hemicrania appear single, and unattended by any other ailment for several years, and thus isolated from every other symptom, assume all the character 266 ANDRAL'S MEDICAL CLINIC. of a true neuralgia ; it is, however, very probable that it depended on the organic lesion of which the brain was the seat. The alteration of motion came on suddenly, as if the cerebral sub- stance had become the seat of hemorrhage or softening. It is not in this way that the paralysis usually commences, which depends on a cancerous affection of the brain, and that is, no doubt, one of the most remarkable circumstances of this case. What is not less worthy of attention is, those species of periodical paroxysm, the probable result of an intermittent cerebral congestion, during which the patient sunk into a profound coma, presented the tracheal rattle of one in the last agony : the latter disappeared as well as the coma, the intellect was restored, and immediate death was no longer to be apprehended. This we observed several times ; death came on at last in consequence of the continuance of a similar paroxysm. Case 2.—Hemiplegia of long standing preceded by pains occupying the side of the cranium opposite to the paralysis—Mind sound; suddenly a violent attack of epilepsy, followed by profound coma, in which the patient died. A man, forty-seven years of age, was affected with complete hemi- plegia of the right side when he was seen by us. This person, who still retained all his intellect, told us that for the last three years he habitually felt in the left side of the cranium a pain which he at- tributed to rheumatism ; he had had several attacks of this latter affection. The pain which he felt never entirely ceased ; but though in general rather dull, it became occasionally much more acute, and then was accompanied by copious vomitings of a green substance. He considered this periodical exasperation of his headache a megrim. For two years he experienced no other uneasiness but this pain of head, which did not, however, prevent him from attending to his usual avocations. At the end of this time, and after one of these megrims, which had been very violent, and which was continued beyond the ordinary period, he began to feel in the hand and foot of the right side an annoying formication, which went away of its own accord after some days. Two months after he had another attack of megrim as violent as the preceding, and after it the same sense of formication reappeared. But this time it continued, and the right extremities soon became weaker than those of the left side, and then completely paralysed. The paralysis was not complete till about eight months after the first appearance of the formication. When we saw the patient he had constant pain of the head ; the muscles of the face were the seat of slight convulsive twitches, re- sembling a sort of tic, which were not perceived by the patient. The extremities of the right side were completely deprived of mo- tion, and the skin covering them was much less sensible than that of the extremities of the left side ; the organs of the senses not affected ; pulse sixty-eight, regular and full. Ten or twelve days passed on without any change in the state of the patient. At the end of this time the pain of the head became suddenly aggravated; his features were very much altered by the DISEASES OF THE BRAIN. 267 pain ; he cried out aloud for some relief; he vomited during the time an enormous quantity of green bile ; the pulse had become very frequent, and the muscles of the face much more violently convulsed than usual. In this state we were desirous to try the effect of a bleeding ; sixteen ounces of blood were taken without any amend- ment. A little time after this the patient suddenly lost all conscious- ness, convulsive movements appeared, and all the phenomena characterising an epileptic attack were observed. The convulsions soon ceased, but they were succeeded by a profound coma, in which the patient died during the night. Post mortem.—A. cancerous mass, the size of a pullet's egg pos- sessing the same characters as those described in the preceding case occupied the central part of the left hemisphere of the brain ; it had taken possession of the optic thalamus and corpus striatum of this side ; the entire encephalic mass was very much injected. The organs in the other cavities was sound. Remarks.—This tedious disease terminated by a violent attack ot epilepsy, and commenced as that detailed in the first case, by a headache which for a long time did not appear connected with any serious lesion. Between these extreme periods we observe that a paralysis occurs, which is established gradually, and commences after one of the aggravations of the headache. The intellect continued more perfect here than in the subject of the first case. We shall see, on the contrary, the disturbance of this function very well marked in the subject of the following case. Case 3.—Temporary signs of mental alienation—Intellect habitually very obtuse— greater and death6 eXtremitieS °f the right side-P™stration of strength becoming A woman, forty-eight years old, entered La ChariU with her in- tellect so dull that we could obtain no information respecting the previous history of her case. The questions put to her she answered very vaguely: she scarcely knew where she was. All we could learn from those who brought her was, that when she had her in- tellect, she suffered at different times from attacks of mania, for which she was admitted twice into the Salpitrilre. By degrees she fell into a sort of idiocy, and it became necessary to attend her as a mere infant. She had also strong contraction of the upper and lower extremities of the right side. Since her admission, this woman was very much debilitated ; tongue dry, and an eschar already formed on the sacrum. The following days the adynamic state became more and more marked, severe diarrhoea came on, the respiration stertorous, and the patient died shortly after. Postmortem.— The vault of the cranium had been hardly re- moved, and the dura mater cut into, when we were struck with the uneven appearance of the convolutions of the middle lobe of the right hemisphere; they were very much deformed, and very differ- ent irom those of the opposite side. We found them very hard ; they sounded under the scalpel. This unusual hardness extended 268 ANDRAL'S MEDICAL CLINIC. in depth to a little above the level of the centrum ovale of Vieussens, the optic thalami and corpus striatum not being at all affected. In every part where the cerebral substance was thus hardened, it was at the same time changed into a fatty (lardaci) tissue which had all the characters of scirrhus ; in several parts it was marked by small cavities, which were filled with a greyish white substance, like glue. Three or four cretaceous tubercles, surrounded by a black indurated tissue, were found in the summit of the two lungs. The mucous membrane of the stomach presented a slate-coloured tint, and a greater consistence than natural in all the pyloric portion ; towards the great curvature it was reddish and soft. The mucous membrane of the end of the ileum, and that of the caecum, were very much injected without being softened. Remarks.—Here is a case in which the symptoms of cancer of the brain are no longer the same, in some respects, as in the first and second case. At first, instead of simple paralysis, there was contraction of the limbs ; but what particularly distinguishes this case from the two preceding ones is, the disturbance which the intellect underwent, namely, those temporary alterations of reason which terminated finally in a kind of madness. In these three cases the nature of the lesion was identical; but it had not the same seat : in the two former the convolutions re- mained sound, in the third they were affected. And without intending to draw any general conclusions, we cannot help remark- ing that it was only in the case where the circumference of the brain participated in the cancerous degeneration that the intellectual faculties were affected. It is not pathological anatomy that can here inform us, why, in the two first cases there was simple paralysis, and contraction in the third case. We cannot but remark, also, the entirely different manner in which death came on in these three cases. Here we observed no coma, no epileptic or other convulsions; we find mere prostration of strength gradually increasing, induced, in some degree, no doubt, by the state of the digestive tube. Case 4.—Cancer of the brain, in the kidneys, and in several of the bones—Paralysis of one of the upper extremities—Headache—Remarkable state of apathy. A man, forty-five years old, complained to us, when entering La ChariU, of a pain in the left coxo-femoral articulation, the parts surrounding which were the seat of considerable swelling. We found also most of the signs of fracture of the neck of the femur; shortening of the limb ; turning of the point of the foot outwards; inability to flex the thigh on the pelvis, the leg being extended on the thigh ; the left great trochanter more projecting, and nearer the crest of the ileum than that of the opposite side ; all motion of the joint impossible. The patient assured us he had not had a fall; that he never had suffered any external violence. The face had a very remarkable pale yellowish hue. Another phenomenon struck us, namely, complete paralysis of the whole left upper extremity. DISEASES OF THE BRAIN. 269 The patient told us that he had insensibly lost the use of this limb ; about six or seven months since, he perceived that he could not use it with as much ease as the other : from time to time he had experi- enced acute pains in it. He said that, for the last five or six months he was annoyed by an almost constant headache, principally seated in the right side of the cranium ; he complained of no pain in any other part of the body. The digestive and respiratory functions were regular ; the pulse was somewhat accelerated. This man who seemed to labour under an affection purely surgical complained of nothing : he scarcely answered the questions put to him ; and we were struck every morning with the state of apathy in which he seemed to be sunk. In consequence of lying constantly on his back, his sacrum became excoriated ; this excoriation was ultimately converted into a large ulcer, which went on increasing in depth and breadth. From this time he became weaker, his tongue dry and black, his teeth and lips were covered with dark coloured crusts. For the last twenty-four hours of his life, his res- piration became remarkably slow ; each inspiration seemed to be his last, so long was the interval between them, and he died. Post mortem.—We found the left optic thalamus and nervous substance surrounding it, changed into a lard-like tissue, possessing all the characters of cancerous matter. No other morbid change was found in the encephalon. A frothy, colourless serum flowed in great abundance from the two lungs. The mucous membrane of the stomach had for the greatest part of its extent a slate-coloured tint. The left kidney was occupied, for at least the three fourths of its extent, with a dull white tissue traversed by numerous reddish lines : being hard in certain parts, this tissue resembled in other parts softened cerebral substance : the degeneration of the parenchyma of the kidney into encephaloid tissue eould not be mistaken. The same alteration existed in the right kidney, but to a less extent. The head of the left femur was entirely separated from the body of this bone ; in the place of its neck, the bony structure of which was entirely destroyed, there was found a half liquid substance, of a brick-red colour, similar to the reddish detritus resulting from the softening of the encephaloid tissue. A similar substance filled the interior of the head of the femur, which consisted merely of a hollow sphere with very thin parietes. It is probable that, in a little time more it would have entirely disappeared. The upper extremity of the lower portion was marked with numerous asperities. The third, fifth, sixth, and seventh ribs on both sides, presented several solutions of continuity' ; and in the place which should have been occupied by the destroyed bony tissue, there was found a reddish substance similar to that interposed between the head of the bone and its body. The sixth rib on the right side presented three similar solutions of continuity. On examining the bones of the cranium, we found that the right parietal presented at its anterior and middle part, an irregularly rounded perforation, large enough to admit the end of the thunb : this was filled by the same reddish matter already Oct. 1838.—L 25 270 ANDRAL'S MEDICAL CLINIC. described. This substance was spread over the dura mater to an extent at least three or four times greater than thatof the perforation itself : beneath it the dura mater was sound. The first piece of the sternum was in a great measure changed into this same reddish substance. Remarks.—Pain of the head, of several months' standing, but which was no longer exasperated at intervals as in the preceding cases ; a paralysis gradually established, the existence of which could be ascertained only in the upper extremity opposite to the injured hemisphere ; finally, towards the latter period of the disease, a remarkable kind of apathy : such were the only symptoms indica- ting in this individual cancer of the brain : but this cancer was only one of the elements of the disease under which he laboured. The reader's attention is directed to the appearance of this cancer- ous affection both in the bony system and in the urinary organs. Case 5.—Cancer of the brain, liver, spleen, stomach, uterus, ovaries, and of a great number of lymphatic ganglions. A woman, about forty years of age, presented nothing else during her stay at La Pilii but the ordinary signs of cancer of the uterus. With respect to the nervous centres she evinced no appreciable functional disturbance : she died of pleurisy of the right side which terminated in a sero-purulent effusion. Post mortem.—A small cancerous mass, the size of a pea, in the left corpus striatum ; another, the size of a nut at the junction of the middle and posterior lobes of the right hemisphere ; effusion into the right pleura ; numerous cancerous masses in the liver and spleen ; scirrhus thickening of the tunics of the stomach around the pylorus ; cancerous degeneration of the body and neck of the uterus and also of the ovaries. Remarks.—In this case, as in the preceding, the cancer found in the brain was but an element of a more general disease. The absence of cerebral symptoms may be accounted for by the small size of the cancerous masses found in the brain. THIRD BOOK. DISEASES OF THE CEREBELLUM. These diseases are much rarer than those of the cerebral hemispheres. We collected but sixteen in a period of fifteen years of attendance in the hospitals. We will record them, and bring in juxta-position with them those already published by different writers; and will then endeavour to draw from the comparative study of these different cases, some consequences relative to the functional disturbances occasioned by lesions of the cerebellum. DISEASES OF THE BRAIN. 271 SECTION I. OBSERVATIONS ON HEMORRHAGE OP THE CEREBELLUM. In the six following cases hemorrhage of the cerebellum alone ex- isted three times; and three times it coincided with an effusion of blood into one of the cerebral hemispheres. Cases.—Effusion of blood into the right hemisphere of the cerebellum—Hemiplegia on the left side, accompanied with loss of consciousness—Death fifty hours after the appearance of the first apoplectic symptoms. A female, twenty-one years of age, was treated at La ChariU for a chronic gastritis, of which she evinced symptoms for the last two years. One evening at six o'clock, a little time after having eaten, and before going to bed, she fell, suddenly deprived of consciousness and motion ; after about an hour she recovered the use of her senses, but could not move the extremities of the left side. On seeing her the next morning her state was as follows :—Face injected equally on both sides ; contraction of the pupils ; vision preserved ; air of stupor ; she answers questions with correctness ; no embarrassment of speech. The two extremities of the left side completely deprived of voluntary motion ; they presented no trace of contraction ; sensi- bility of the skin covering them impaired. Pulse seventy-five and full ; heat of the skin natural; respiration hurried (thirty to thirty- four every minute). This girl seemed to us to have been struck with cerebral hemorrhage; she was bled to sixteen ounces. At the following visit her state was much worse ; she was sunk in a profound coma; does not any longer answer questions; skin insensible to the action of excitants, on the right as well as on the left side. The extremities of the right side, when raised, sustain themselves for some seconds in the air, and fall back gradually ; not so the extremities of the left side, which fall like inert masses ; respiration very stertorous. In the course of the day the symptoms of carus became more and more marked, and the patient died at eight o'clock at night. Post mortem.—Cranium.—Sub-arachnoid cellular tissue of the convexity of the cerebral hemispheres very much injected. The latter present no appreciable alteration,except considerable sandiness of their tissue. In the central part of the right hemisphere of the cerebellum was found an effusion of blood, which formed in the nervous substance a cavity large enough to hold a pullet's egg. Around this cavity the tissue of the cerebellum was red and softened for the space of three or four lines. Thorax.—Sero-sanguinolent infarction of the two lungs, and par- ticularly of the left. Heart and its appendages natural. Abdomen.—Scirrhous induration of the sub-mucous cellular tissue of the stomach in all its pyloric portion. Beneath this tissue considerable hypertrophy of the muscular tunic, which was divided into large fasciculi by whitish lines belonging to the thickened eel* 272 ANDRAL'S MEDICAL CLINIC. lular tissue. In some parts, no trace of the fleshy tunic, and there is nothing found but a homogeneous scirrhous mass. The mucous membrane of a slate-colour hue, and thickened. Case 2.—Hemorrhage into the right hemisphere of the cerebellum—Sudden loss of consciousness—Hemiplegia on the left side—Death very rapid. A man, thirty-eight years of age, entered La ChariU in the course of the month of March, 1824, presenting all the symptoms of an organic affection of the heart. A well-marked bellows sound was heard at each contraction of this organ. After complaining for some days of dizziness and headache, the precise seat of which he was unable to point out, he was struck with a violent fit of apoplexy : coma, sudden and profound ; general insensibility to external stimu- lants. As yet, no real paralysis except on the left side : if the limbs of the right side be raised, they fall again but slowly ; if those of the left side be raised, they fall suddenly, as inert masses. On pinching the skin severely, the extremities of the right side are seen to move, at the same time that the muscles of the face contract, and a slight moan is heard ; on the contrary, the extremities of the left side are immoveable. Such was the state in which we saw the patient at our visit, about fifteen hours after the attack ; the respiration was very stertorous; pulse not frequent, but compressible ; it presented many irregulari- ties ; this state appeared to us to be connected with the affection of the heart. He died a few hours after the visit. Post mortem.—Cranium.—No appreciable lesion in the cere- bral hemispheres, nor in the membranes covering them. Right hemisphere of the cerebellum transformed into a sort of pouch filled with black blood similar to currant-jelly. Thorax.—The heart presented an unusual size, depending on the abnormal state of the auricles ; they were both considerably dilated, and their parietes very much hypertrophied ; the right auriculo- ventricular valve was hard and thickened, particularly at its free edge. In the left, the mitral valve was still more thickened, carti- laginous in some points, and bony in others. It constituted a ring or immoveable diaphragm, through the opening of which the index finger could scarcely be introduced. The aortic valves were ossified at their base. The ventricles preserved their normal state. Case 3.—Effusion of blood into the left hemisphere of the cerebellum—Hemiplegia on the right side—Intellect dull—Subsequently a fall—State of coma—Death. A woman, seventy-five years of age, entered La ChariU in the following state:—Countenance pale, expressive of stupor; the in- tellect very dull ; complete paralysis of the extremities of the right side ; tongue dry and brown ; diarrhoea ; pulse frequent; skin hot. We obtained no information of the preceding history. For the five or six following days no change took place. At the end of this time, the patient, wishing one morning to leave her bed, DISEASES OF THE BRAIN. 273 fell, and was deprived of consciousness ; from that time there was coma ; general relaxation of the limbs ; death two days after the fall. Post mortem.—Cranium.—Pia mater covering the convexity of the cerebral hemispheres was infiltrated with serum; there was a great quantity also in the ventricles. Clots of blood filled the occipital fossa of the left side ; this blood escaped through a rent which was perceived in a point of the ex- ternal posterior part of the circumference of the left hemisphere of the cerebellum. By pressing on this hemisphere, more was made to flow from it. The rent just alluded to led us by a canal which was fistulous, shorthand filled with blood, in the midst of a cavity formed in the substance of the lobe of the cerebellum itself, and large enough to admit at least a large nut. This cavity contained black blood, half liquid, half coagulated. Its parietes were lined by a reddish mem- brane of about a line in thickness, easily detached from the subjacent tissue. Around this cavity the substance itself of the cerebellum was not softened, and had not undergone any alteration. Thorax.—Considerable infarction of the lungs. Hypertrophy of the parietes of the left ventricle of the heart; some points of ossifi- cation towards the adherent edge of the sigmoid valves of the aorta. Abdomen.—Reddish softening of the mucous membrane of the stomach towards its great curvature. The cavity of the uterus filled with blood, and the tissue of the body of this organ intensely red. Case 4,—Double effusion of blood: one into the left hemisphere of the brain, and the other into the left hemisphere of the cerebellum—Hemiplegia on the right side. A man, sixty-three years old, was struck, on leaving the table, with an attack of apoplexy. He was brought the same evening to La ChariU. When we saw him the following morning, he had partly recovered consciousness; he understood the questions put to him, but answered stammeringly, and in a way almost unintelligible; The left commissure of the lips drawn up ; we could not prevail on him to put his tongue out. Right eye lid more depressed than the left; sensibility of the two sides of the face apparently equal; sees equally well with both eyes ; arm and leg of the left side capable of motion of every kind, but the extremities of the right side re- mained immoveable : all possible positions were given them, without the slightest resistance being made ; the skin covering them felt less acutely than on the other side. Respiration high and frequent (bleeding to sixteen ounces, purgative mixture, sinapisms to the lower extremities). The following morning we found the patient in the same state. Blood drawn not buffed ; purgative acted well (thirty leeches to the neck, blister to each thigh). During the day new symptoms appeared. The patient, who, till then, had remained in a state of apathy, began to be very much disturbed, and to rave ; he cried and spoke incessantly. Towards evening he fell into a state of coma and died in the night. Post mortem.—The pia mater, covering the convexityT of the 25* 274 ANDRAL'S MEDICAL CLINIC. hemispheres, was very much injected ; this injection more marked on the left than on the right side. The grey substance of the convolutions showed a well-marked rose-coloured tint. About one inch below the convolutions of the left hemisphere of the brain, there appeared an enormous cavity filled with black blood half coagulated : this cavity terminated on the level of the centrum ovale of Vieussens ; it occupied all the middle lobe, and a little of the exterior and posterior lobes. Around it the cerebral substance was, as it were, ecchymosed for a space of four or five lines ; it lost its consistence only for the space of one or two lines from the cavity ; no membrane lined the parietes of the latter. No other lesion existed in the cerebral hemispheres ; much serum accumu- lated in the ventricles. A second effusion of blood existed in the centre of the left hemi- sphere of the cerebellum. The accidental cavity produced by it might admit a nut ; around it the tissue of the cerebellum was con- siderably injected without being softened. However, a stream of water poured on the thin parietes of this cavity, displayed there a great number of red or whitish filaments, resulting from the tearing of the nervous substance. Case 5.—Two attacks of apoplexy ; three months intervening between each—Hemi- plegia of the right side after that of the first attack—Apoplectic cyst in the left hemi- sphere of the cerebellum—Recent hemorrhage in the right hemisphere of the brain. A woman, aged sixty-seven years, had had an attack of apoplexy two months and a half before entering La ChariU. After this attack, of which the symptoms could not be narrated to us with sufficient precision, she remained paralytic on the right side. When we first saw her, motion was entirely abolished in the two extremities of this side, and their sensibility impaired ; intellect and speech ready; the senses not affected. After remaining fifteen days in the same state, she was struck with a second attack of apoplexy, of which she died in the course of some hours. Post mortem.—An immense effusion of blood into the right hemisphere of the brain ; it took possession of the optic thalamus, corpus striatum, and a considerable portion of the nervous mass above and external to these parts ; the effused blood has the colour and consistence of currant jelly ; the effusion evidently quite recent. In the left hemisphere of the cerebellum, on the contrary, was another lesion of an older formation, indicating that an old hemor- rhage had taken place in this part. The cavity here is large enough to admit a nut, and contains a clot of blood of a brown red colour, and solid, around which was formed a membrane entirely resem- bling a serous one : the adjoining substance of the cerebellum is a little soft and yellowish. Case 6.—Double hemorrhage, one of which is in the right hemisphere of the cere- bellum, and the other in the left hemisphere of the cerebrum—Hemiplegia on the right side—Loss of consciousness. A hotel keeper, forty-nine years of age, fell in the street deprived of consciousness, after having indulged in excessive drinking. He DISEASES OF THE BRAIN. 275 was instantly conveyed to the Maison de SanU, and was bled to a considerable amount. For the first hour after the bleeding there seemed some return of consciousness, which, however, was soon again succeeded by profound coma. The following morning when we saw him, he was in a state of stupor from which nothing could arouse him ; the strongest pinch- ing seemed to have no effect on him ; vision gone ; the loudest noises near his ear produced no movement in him ; the four extre- mities were immoveable, in a state of relaxation, an'd seemed as incapable of motion on one side as on the other. Still we were assured that the evening before, after being bled, he moved the extremities of the left side with ease, whilst those of the right side seemed paralysed ; face red, and injected ; pulse hard and frequent; skin hot. We had him bled again to twenty ounces, and ordered twenty leeches to be applied after the bleeding to each mastoid process, which were let bleed the entire day, whilst a bladder full of ice was applied to the head, and sinapisms to the lower extremi- ties. Towards the end of the day the patient emerged from his state of coma ; he seemed to recover a little intellect. When we saw him again his eyes were open, and he seemed to pay some attention to the questions addressed to him ; however, he seemed not to understand them, and did not answer. The left angle of the com- missure of the lips was drawn back, and the tongue when put out of the mouth inclined to the right. He moved the left extremities with ease; those of the right side was completely deprived of motion, and the sensibility of the skin covering them was very much impaired ; the pulse was slow; the respiration hurried, but not stertorous; neither was it the preceding day. (A blister was applied to the nape of the neck, ice to the head still continued.) ; In the course of the day the patient relapsed into coma, and he died in the night. Up to the last moment he had the power of moving the extremities of the left side. Post mortem.—A large effusion of blood occupied at least the third of the left cerebral hemisphere; it commenced a little beneath the convolutions, which were sound, and affected the optic thalamus and corpus striatum ; it made its way into the left lateral ventri- cle. The septum lucidum was not torn. A second effusion of blood was discovered in the right hemi- sphere of the cerebellum, and occupied the half of this hemisphere ; it was nearer to the upper than the lower surface. Remarks.—In the six preceding cases, the hemorrhage of the cerebellum differs in nothing, with respect to the symptoms, from hemorrhage of the cerebrum. In all these there is paralysis, and it occurs on the side opposite to that on which the effusion of blood takes place, except in the last case, which forms an exception. From these facts, we feel warranted in concluding that irritation of the cerebellum passes to the opposite side of the body, as do those of the brain, and yet the 276 ANDRAL'S MEDICAL CLINIC. fibres of the spinal marrow which enter into the corpora restifor- mia, do not come from the opposite side of this cord. The argument which had been considered available to explain the crossing influence of thehrain, is no longer so here. The intellect presents in its disorders the same varieties as in the cases of hemorrhage of the brain ; so that these disorders seem to depend less on the seat of the lesion than on its intensity. The sensibility undergoes no peculiar aberration : it is merely impaired or destroyed, as in cases of cerebral hemorrhage. With respect to the genital apparatus, it presents nothing remark- able, except in the woman who forms the subject of the third case. In her there was considerable congestion of the uterus. We satisfied ourselves that in the males there was no erection of the penis, because they were entirely uncovered, and were examined naked, in order to ascertain the state of the lower extremities. The disease begins the same way as in the individuals whose brain, properly so called, is the seat of hemorrhage. Thus we see our patients fall suddenly deprived of consciousness, and become at the same time struck with paralysis. Let us now add to these six cases observed by ourselves, those others of hemorrhage of the cerebellum published up to the present time. We have found in medical authors twenty-two cases of hemor- rhage of the cerebellum, nine of which were in the middle lobe, and thirteen in the lateral lobes. Of the nine cases relating to hemorrhage of the middle lobe, six have been published by M. Serres.* In these six cases, all the signs of violent apoplexy were observed ; nothing particular is mentioned regarding the disturbances of motion. A seventh case of hemorrhage of the middle lobe has been men- tioned by Dancet, in his paper on acute hydrocephalus. The sub- ject of this case was struck with apoplexy ; no account is given of the movements of the limbs. An eighth case, relative to this hemorrhage, was published by M. Bayle. The patient suddenly lost consciousness, but he was not paralysed ; at least, M. Bayle assures us, that he drew back his limbs instantly when they were touched. This individual died comatose on the fifth day of his attack, after having exhibited, on * the third day, convulsive movements in the lower extremities, and some rigidity towards the nape of the neck. We read in the Clinique des Hbpitaux (torn. i. No. 70), a case of M. Guiot, in which there is not found, as in eight others, any other lesion than an effusion of blood into the middle lobe of the cerebellum. The subject of the case had an attack of apoplexy. Before he was struck, he walked unsteadily, and, after the attack, he remained hemiplegic on the left side. * Anatomie du Cerveau, torn. ii. j Archives de M£decine, Jan. 1830, p. 42. DISEASES OF THE BRAIN. 277 Thus, then, in these nine cases of hemorrhage of the middle lobe of the cerebellum the paralysis is absent once ; it is limited to one side in another case ; in the seven other cases, the limbs seem to be in a general state of relaxation, as happens in large cerebral hemor- rhages. In these nine cases the intellect and sensibility present the same modifications, as they would have presented if the hemorrhage were seated in one of the cerebral hemorrhages. The genital apparatus is, on the contrary, modified very particu- lary in seven of these nine cases, whether male or female. First, in the male, M. Serres saw five times (the subject of his sixth case was a female) the phenomenon of erection coincide with hemor- rhage of the middle lobe. This same phenomenon was noted in the case published by M. Guiot. Still further, in this case, the patient, before the attack, was attacked by continual, erections and frequent pollution. The female who formed the subject of M. Serres' case was seventy years of age. Her menses reappeared at the time she was struck with apoplexy ; and after death her uterus was found filled with blood, and the tubes and ovaries considerably injected. We shall now pass on to the analysis of the thirteen cases, where the hemorrhage took place in one of the hemispheres, or of the lateral lobes of the cerebellum. These cases, as also the six already cited, may be divided into two series : in the first, the hemorrhage of the cerebellum exists without cerebral hemorrhage ; in the second, these two kinds of hemorrhages co-exist. The first of these series comprises seven cases : in three of them only is there paralysis, and in all three it took place on the side op- posite to the seat of the effusion into the cerebellum. Of these three cases, two were seen by M. Serres. The right hemisphere of the cerebellum was the seat of the hemorrhage, and there was hemiplegia of the left side.* The third case was published by Dr. Cazes in his Thesis.t The subject of his case was a female, seventy-four years of age, who, after having had for some time a great tendency to stupor, lost consciousness quite suddenly, and fell into a profound carus. When the extremities were pinched severely, those of the left side were seen to perform considerable movements ; the right lower extre- mity continued entirely motionless ; the upper extremity of the same side moved, but in a manner almost imperceptible. This woman died eight hours after having been struck. On examining the body. M. Cazes found the left lobe of the cerebellum changed into an immense cavity filled vvith coagulated blood. In the four other cases of hemorrhage of the cerebellum, without co-existence of cerebral hemorrhage, there is no mention of hemi- * Anatomie Compared du Cerveau, torn. ii. p. 215. | Essai sur la Paralyse, par Felix Cazes, 1824, No. 3. 278 ANDRAL'S MEDICAL CLINIC. plegia. Thus one of these four cases recorded by Morgagni,* refers to a man, who was found dead, vvith the upper extremities strongly contracted ; there was an effusion of blood into each of the lateral lobes of the cerebellum. Another of these cases was attended by Dr. Sedillot,t and was of a child seven years old, who after being exposed to a burning sun, was suddenly seized vvith acute pains towards the occipital region: he died a quarter of an hour after the appearance of the pains. An effusion of blood was, in this case, in the centre of the right lobe of the cerebellum. A third case, reported by Dr. Cafford,J contains so few details, that it can be of no use in solving the question now before us. It is merely said, in this case, that in an individual who died of apo- plexy, blood was found effused on the surface of the cerebellum and into its grey substance. With respect to the fourth case, published by Dr. Michelet in his Thesis,§ it is deserving of all our attention. This was the case of a girl eighteen years of age, who, two years before her death, had had an attack of apoplexy, the result of which was amaurosis without any other paralysis, and habitual head- ache. An apoplectic cavity of an old standing was found in the right lobe of the cerebellum. Let us now pass to the cases in which there was, at one and the same time, hemorrhage into the cerebellum and the cerebrum. Eight cases of this kind have been published. In one of these cases only the effusion of blood took place into the hemisphere of the cerebellum and cerebrum of the same side; it was on the left, and there was observed a hemiplegia on the right, the left extremities retaining all the freedom of their move- ments. |j In the seven other cases it was in the opposite hemispheres of the cerebrum and cerebellum that the hemorrhages took place. Thus, there was observed, in the wards of M. Piorry, the case of an individual, who had at first an attack of apoplexy, with hemiplegia on the right side ; a year after he had a second, but this time it was the extremities of the left side which were paralysed. To account for these two successive paralyses, M. Piorry found two lesions, the one, an old one, in the left lobe of the cerebellum ; it was an old apoplectic cyst: the other recent, in the right lobe of the cerebrum: it was a softening.il In this case the crossing influence of the cerebellum on motion is quite evident, and the successive manner in which the hemorrhage * De SedMbus et Causis Morborum, Epist. ii. § 22. f Bibliotheque M^dicale, torn. xlii. X Archives Generates de Medecine, torn. xxii. § Essai sur les Rougeurs de la Substance C6r6brale, Thesis de laFaculte, 1827, No. 59. [| Chambeyron, Dissertation Inaugurale, 1823. If Lancette Franchise, No. du 17th Octobre, annee, 1829. DISEASES OF THE BRAIN. 279 took place in the cerebellum, and cerebrum, allows us accurately to appreciate the influence of each of these parts. In the other cases, of which we are now to speak, an extraordinary fact presents itself; it is the existence of paralysis only on the side of the body opposite to the cerebral hemisphere which was the seat of hemorrhage, whilst the extremities on the side opposite that to the diseased lobe of the cerebellum remained sound. Two of these cases were published by Dr. Droullain.* In one of them there were two old apoplectic cysts, the one in the left lobe of the cerebellum, the other in the middle and external part of the right hemisphere of the cerebrum ; there had existed a hemiplegia on the left side. In the other case, there was found, in the midst of the left lobe of the cerebellum, a sanguineous effusion the size of a nut, and at the same time there was discovered in the right hemisphere of the cerebrum, between the optic thalamus and the corpus striatum, the traces of an old hemorrhage ; the patient had recently had hemiplegia on the left side. After a fall he exhibited symptoms referable rather to an acute meningitis than any other affection ; alternations of delirium and somnolence ; temporary contraction of the extremities of the two sides; convulsive movements of all the body ; retroversion of the occiput. The different facts which we have now recorded, lead us to the same results as those derived from our own experience. From both series we may draw the following corollaries :— 1st. When the effusion which has taken place into one of the hemispheres of the cerebellum is sufficiently extensive, without being inordinate, it produces paralysis of one side of the body. 2d. The side of the body paralysed is that which is opposite to the hemisphere of the cerebellum, in which the hemorrhage had taken place. This fact has been ascertained both in the cases of simple hemorrhage of the cerebellum, as also in those where there was at the same time hemorrhage of the cerebrum and cerebellum of the same side, or, in other cases, where the hemorrhage of the cere- bellum had preceded that of the cerebrum, both taking place in the opposite hemispheres. M. Piorry's case exemplifies it. 3d. Hemorrhage of the cerebellum does not produce hemiplegia, at least that we could discover, in the cases where there was a very severe attack ; in the latter there is observed a general relaxation of the four extremities, such as takes place also in the cases of abundant cerebral hemorrhage. 4th. When the hemorrhage of the cerebellum occurs simulta- neously with that of the cerebrum, or a little time after it, but so that the blood is effused on the right into the cerebellum, and on the left into the cerebrum, or vice versa, there is paralysis only on the side of the body opposite to the hemisphere of the cerebrum in which the hemorrhage has taken place, that is, on the same side as the hemorrhage of the cerebellum. How then does it come to pass that, * Droullain, Dissertation Inaugurate. 280 ANDRAL'S MEDICAL CLINIC. whereas the movements of the extremities of the right side are abo- lished in consequence of an effusion of blood into the left hemi- sphere of the cerebrum, the effusion which takes place simultaneously into the right hemisphere of the cerebellum, has no longer the power of paralysing the extremities of the left side ? It had this, however, in the cases where the brain remained sound ; and is not that a fact worthy of attention ? 5th. It is not satisfactorily proved that the contraction of the limbs, convulsions, retroversions of the head, which have been observed in a case where there was simultaneous hemorrhage into the brain and cerebellum, depend on lesion of the latter. Have not similar phenomena been observed, in fact, in cases of simple hemor- rhage of the brain ? 6th. Sensibitity, placed by some authors in the cerebellum, has not seemed to us to suffer a special or particular lesion in the cases of hemorrhage of the organ. 7th. The intellect presents the same modifications as when the effusion of blood has taken place into the brain properly so called. 8th. In none of the cases analysed by us, respecting hemorrhage of one of the lateral lobes of the cerebellum, no particular phenome- non presented itself with respect to the genital organs. 9th. The functions of the life of nutrition exibited no modifi- cation different from those presented in individuals who have had hemorrhage of the cerebrum. SECTION II. OBSERVATIONS ON SOFTENING OP THE CEREBELLUM. Softening of the cerebellum has been observed much less frequently than that of the cerebru m ; up to the present time there have been but thirteen cases published, to our knowledge ; eight of these refer to softening of one of the lateral lobes, four to softening of the two lobes together, and one only to softening of the middle lobe. Among these thirteen cases there are but nine in which the cerebellum alone is affected ; in the four other cases there is at the same time an affec- tion of the cerebrum twice, of the pons Varolii once, and of the spinal marrow once. We have ourselves met but four cases of softening of the cerebellum ; we shall now record them. Case 1.—Pain of the head in the occipital region of three months' date—Hemiplegia of the left side established gradually—Latterally convulsive movements of the pa- ralysed limbs—Blindness—Considerable softening of the right lobe of the cerebellum. A seamstress, thirty-one years old, had always enjoyed good health. About six weeks before entering La ChariU, she expe- rienced a fright whilst menstruating: the menses were surpressed, and immediately after their disappearance, she was seized with diz- DISEASES OF THE BRAIN. 281 ziness, and an acute pain in the back part of the head towards the right side. The dizziness disappeared after bleeding, but the pain of head remained ; it was unconnected with any other symptom for eight days ; subsequently the patient began to experience an an- noying sense of formication at the ends of the fingers of the left hand ; she could use this hand but awkwardly, and was aston- ished at seeing what she handled with it always to fall ; she soon became unable to work with it; the entire arm seemed very heavy. After some time, the lower extremity of the left side became weaker, and in about a month the patient had complete hemiplegia of the left side. But at the same time that the patient thus lost the power of motion of one of the sides of the body, her sight, till then quite good, became very imperfect, and five weeks after the ap- pearance of the first symptoms, she became completely blind. This was the state in which we first saw her—deprived of sight, and of the power of moving the limbs of the left side; then the pain of the head became less acute. The patient, however, still felt it, and referred it to the lower part of the occipital region of the right side. The paralysed limbs wTere flaccid, and were moved passively in all directions, the skin covering them still retaining its sensibility ; no trace of paralysis on the face ; the pupils, moderately dilated, still contracted on the sudden approach of light ; the appearance of the eyes natural; there was, however, complete blindness; she could scarcely distinguish day from night; intellect sound,the pulsenatural; the menses had not reappeared since they were suppressed by the fright. Leeches were first applied to the nape of the neck, then to the genital organs ; aloetic pills were frequently given, and subse- quently the back of the head was covered with a blister. No change appeared for the first three weeks of her stay in the hospital; then, without any known cause, the pain of head suddenly became more violent, and extended to the entire cranium : the ex- tremities of the left side, which hitherto had remained entirely immoveable, were several times agitated with convulsive movements which were slight in the lower extremity, but very violent and almost continual in the upper limb ; acute pains accompanied these convulsions ; the intellect soon became disturbed ; complete deli- rium set in ; for twenty-four hours the patient spoke, and became agitated incessantly ; she then fell into a profound coma, in which she died. Post mortem.—The pia mater which extended over the convexity of the cerebral hemispheres was very much injected, as was also that covering the hemispheres of the cerebellum. The substance of the brain, properly so called, was marked with a considerable number of red points, and presented no other lesion ; the lateral ventricles distended With a great quantity of limpid serum ; the fornix and septum lucidum natural. Externally the cerebellum appeared healthy ; but we had scarcely removed some layers of the substance of its right hemisphere, proceeding from above down- wards, when we found an immense cavity, where this substance, Oct. 1838.—M 26 282 ANDRAL'S MEDICAL CLINIC. deprived of its normal consistence, was changed into a greyish mass: this softening occupied at least two thirds of the right hemisphere of the cerebellum ; it partly attacked the prolongation which go from the cerebellum, either to the spinal marrow, or to the tuber- cular quadrigemina, or to the annular protuberance ; it did not extend as far as the lower surface ; in no part of its extent was there either injection or infiltration. Remarks.—This softening, seated in one of the hemispheres of the cerebellum, and occupying a considerable portion of it, presented in its symptoms and progress the greatest resemblance to softenings of the brain. Here again, as in the cases of hemorrhage of the cere- bellum cited above, the paralysis existed on the side opposite to that on which the softening existed. There was neither in motion nor sensation any special disturbance connected with the functions attributed to the cerebellum byT some physiologists. The intellect to be sure retained all its integrity; but was it not also found to be sound in more than one case of softening of the brain ? The seat of the pain alone could incline us to suspect that of the disease. With respect to blindness, it seems at first that it has nothing to do with diseases of the cerebellum, and yet this case is not the only one in which different affections of the cerebellum have been affected by a loss of vision. May this fact be explained by the anatomical relations established between the cerebellum and the tubercula quadrigemina by means of the prolongations known by the name of processus a cerebello ad testes ? The symptoms which super- vened during the latter period should not, in our opinion, be con- nected with softening of the cerebellum : they depended on a com- plication, and we think that we may refer them to the bright red injection presented by the meninges, as well as to the great quantity of serum contained in the ventricles. We know of but few cases in which a softening of the nervous centres succeeded in so marked a manner to a moral impression : the latter had at the same time the effect of suppressing the menses, and it is a remarkable coincidence that in this particular case where there was disturbance in the performance of a function assigned to the genital organs, the same cause which produced this disturbance exercised its influence also on the cerebellum. Case 2.—Pain of head in the occipital region—Hemiplegia of the right side with con- traction—Intellect preserved—Attack of apoplexy of which the patient died— Softening of the central part of the left lobe of the cerebellum—Hemorrhage in the cerebral hemisphere of the left side. A labourer, fifty-three years of age, told us, when entering La PitU, that for the last two months he felt a pain towards the posterior and inferior part of the cranium ; it existed both on the right and left sides : he lost by degrees the power of moving the extremities of the right side, and recently the paralysis of these extremities was complicated with considerable contraction. The sensibility was retained in the paralysed limbs ; motions of the face not changed ; intellect entire. DISEASES OF THE BRAIN. 283 This patient presented no change in his state; only he complained from time to time of feeling dizziness, for which he was bled, and also took some gentle laxatives, and had revulsives applied to the lower extremities. One morning he told us that from the preceding day, his dizziness of head was much more severe than usual; the face was very much injected ; he no longer saw all objects, but through a sort of cloud, and his speech became stammering ; he added that his habitual pain in the back part of the head extended over the entire cranium. Sixteen ounces of blood were taken from him, without any benefit; in the course of the day the vertigo went on increasing; and towards four o'clock in the evening he fell deprived of consciousness. On the following morning he pre- sented all the symptoms of an attack of apoplexy ; entire loss of intellect; profound coma ; general insensibility ; respiration ster- torous : he died in the evening. Post mortem.—General injection of the meninges; rose-coloured hue of the grey substance of the convolutions. An effusion of blood occupied the middle part of the left hemisphere of the cerebrum ; the corpus striatum and optic thalamus were affected by it, and the blood forced its way into the corresponding lateral ventricle. Septum sound ; no appreciable alteration in the right cerebral hemi- sphere ; we were astonished at this ; as we here sought for the cause of the old hemiplegia of the left side, and of the other symptoms experienced previously to the recent attack of apoplexy. This cause, however, existed elsewhere ; in the centre of the left hemisphere of the cerebellum we found a yellowish softening about the size of a nut. In some points this softening exhibited a reddish tint ; around it the substance of the cerebellum was not more injected than elsewhere. Considerable infarction of the lungs. Remarks.—This case resembles the preceding in several respects; the commencement was the same, as were also the symptoms. In both cases the intellect was sound ; in both the power of motion was lost in the limbs opposite to the hemisphere of the cerebellum in which the softening was, and in both the hemiplegia was esta- blished gradually ; but in the first casejthere was but mere paralysis ; in the second there was at the same time contraction of the limbs ; and in this latter alone did some of the softened points exhibit a red tint. In these two cases, in a word, there existed pain of the head at the commencement, the seat of which corresponded with that of the disease. Here, however, there was not blindness as in the first case. Was this because the softening was less extensive, and because also it affected particularly the portion of the lobe of the cerebellum which is especially related to the tubercula quadri- gemina ? There is another point of resemblance between these two cases with respect to the manner in which the disease terminated. In both it was of the brain affection that the patients died ; there having been congestion of this organ in the first, and in the second a hemorrhage which was itself preceded by cerebral hyperemia, that 284 ANDRAL'S MEDICAL CLINIC. did not yield to bloodletting. It is remarkable that the apoplectic attack occurred a few hours after the bloodletting. Case 3.—Sudden loss of consciousness, and of motion of the extremities of the left side—Re-establishment of the intellect—At the end of nine days, a new attack of apoplexy, and death—Considerable softening of the right hemisphere of the cere- bellum. A shopkeeper, twenty-nine years of age, was in the habitual enjoy- ment of good health. One morning, having breakfasted as usual, and being engaged in his shop, he suddenly uttered a loud cry, put up his hand to his head, and fell to the ground deprived of conscious- ness. For the first few minutes after this, his four extremities were agitated with convulsive movements, which subsided, and the patient remained in a stupor: he was bled. After about three quarters of an hour, the stupor ceased ; the patient came to himself; he recovered his consciousness ; speaks freely; has no recollection of what is just past; but the entire left side of the body was de- prived of motion. Thirty-six hours after the attack, he was removed to the Maison de SanU, and presented the following state:— Face pale; complete paralysis of the two extremities of the left side; no confraction of the limbs; diminution of the sensibility in the paralysed limbs ; mind clear; speech free ; no pain of the head; pulse free from frequency ; respiration natural. Hemiplegia was, in this case, the only marked symptom ; during the following week no new symptom was observed; but at the end of this time the severe symptoms exhibited by the patient, at the commencement of his disease, reappeared: the same loss of con- sciousness ; the same convulsive movements, which were of short duration; but the stupor which succeeded them was not temporary, as at first; it became, on the contrary, more and more profound; the respiration was laboured, and the patient died in a state of coma. Post mortem.—We found in the nervous centres no other change than considerable softening of the right hemisphere of the cere- bellum. More than two-thirds of this hemisphere were converted into an inorganic mass, the colour of which varied according to the points examined. The softened mass presented in no part any effused blood. Remarks.—This case differs from the two preceding, both in the nature of the symptoms, and in their mode of development. Here, in fact, the paralysis was established suddenly ; it attained all at once its highest degree of intensity ; the disease commenced by a complete loss of consciousness, accompanied vvith convulsions. At first it might have been taken for a fit of epilepsy, and what would have strengthened one in this opinion was, that at the end of a very short time, the intellect returned, without the patient retaining any recollection of what had passed. All that remained of the serious symptoms was the hemiplegia ; but we have more than once seen epileptic patients, who, after each fit, also remained paralysed on DISEASES OF THE BRAIN. 285 one side of the body for a certain time. This hemiplegia still continued in all its intensity, when, at the end of eight or nine days, there came on a second attack, which, also, in its symptoms very much resembled those of epilepsy. This second attack was fatal. Nothing certainly in this case could have enabled us to fore- see the seat of the morbid change which caused all these symptoms; even the pain of the occipital region was here wanting, which existed in cases 1 and 2. Case 4.—Pain in the occipital region—Convulsive agitation of the limbs—Difficulty of respiration—Softening of the left hemisphere of the cerebellum. A groom, aged nearly forty years, had always enjoyed good health, when he was seized with violent pain of head, accompanied with dizziness: a bleeding, a few days after, diminished, without however removing, these symptoms, and he remained the fifteen days follow- ing with headache, vertigo, and a feeling of debility which pre- vented him from working as usual; his appetite, also, was somewhat impaired. After this time a more serious state suddenly set in ; the pain which till then occupied the entire head, was concentrated towards the occiput, and became at the same time much more acute; he kept to his bed, and after having been bled again, he was conveyed to the Maison de SanU, where he presented the following state:— He answered questions with some difficulty, as one who scarcely understood what was said to him ; in other respects his answers were rational; when asked where he felt pain, he pointed his hand to the occiput, and more particularly" towards the left side of this bone ; he moved his four extremities with equal facility, and the sensibility in them was not changed. Vision was much weaker on the right than on the left; there was no difference, however, between the two pupils. Pulse not frequent. Thirty leeches were applied to the base of the occipital bone, and a purgative was administered. The three days following, the patient was in a state of continual agitation ; the motion of the limbs on both sides was at times so sudden and irregular that they appeared to be convulsive. He constantly complained of his head, and directed his hands inces- santly to his forehead. The respiration, which was calm on the first day, became very much impeded ; it was performed as it were in jerks, and it would appear that the muscles destined to execute this function participated in the convulsive moments of those of the limbs. He soon died in a state of asphyxia. Post mortem.—Meninges injected; nothing particular in the hemispheres of the cerebrum ; a small quantity of serum in their ventricles; reddish softening of the left hemisphere of the cere- bellum in its posterior and inferior half. Remarks.—Here is a case in which the softening of the cere- bellum presented itself to us with symptoms very different, in certain respects, from those observed in the three preceding cases. 26* 286 ANDRAL'S MEDICAL CLINIC. Here there was no paralysis, and the only change noticed in the power of motion, was that singular and irregular agitation of the limbs, both on the right and left side. But here again we find the occipital pain which also existed in cases 1 and 2, and still further vision was weakened in the eye opposite to the affected lobe of the cerebellum ; an important fact, since we find it in several cases of affection of the cerebellum. Another phenomenon deserving of remark, was the embarrassment of the respiration. There was a direct influence exercised in this function, or, at least, on the muscles which serve to perform it, by the morbid state of the cerebellum. The four cases now cited, bear a strong resemblance to those which have been already published by different authors, and the differences which they presented to us with respect to the nature of the symptoms are also found in the latter. We shall now present an analysis of thirteen cases, four of them within our own observation: namely,—the four preceding cases ; and nine of them which have been collected by others.* In these thirteen cases the mind presented the following state :— Frequently it continued sound throughout. In one case, being at first sound, it became disturbed towards the end, and some delirium came on during the last twenty-four hours ; but in this case, which is our first, there was found, on examining the body, considerable injection of the membranes and of the cerebral substance. In two other subjects, the intellect, without being lost, became dull, as occurred in the subject of our fourth case, and in another quoted by M. Monod. In three other instances the disease commenced with sudden loss of consciousness. In one case it was some days after the attack of a continued fever that the patient fell into coma. In two cases the speech was altered; it was not lost, but merely became embarrassed in the subject of M. Monod's case ; it was, on the contrary, completely lost in a case cited by M. Lallemand, in which the cerebellum was the only part of the nervous centres appreciably altered. YVhilst the changes with intellect were variable, inconstant, and of little importance, the lesions of motion, on the contrary, were observed in all the cases except one ; and again, in this case it is not quite certain that motion was not impeded. It is said that the patient fell into coma ; but there does not appear to be anything certain with respect to the state of the limbs, and, besides, this case leaves some doubts regarding the nature of the alteration of the cerebellum. There remain then twelve cases, out of thirteen, in which the power of motion is evidently changed. * Parent Duchatelet et Martinet, Traite sur 1' Arachnitis, p. 420. Rostan, Ramolhssement du Cerveau, 2d Edit, p.143. Lallemand, Maladies l'Encephale, Lettre u. p. 34; Lettre v. p. 330. Serres, Anatomie du Cerveau, torn. ii. p. 616 (Deuxieme Observation). Chambeyron, These. Dany, Memoires de Medecine Militaire, torn. xxii. p. 379. Monod, Nouvelle Biblioth^que Medi- cate, 1828, torn. iii. p. 74. DISEASES OF THE BRAIN. 287 In two cases, the alteration consisted in a sort of convulsive agita- tion of the limbs, this agitation being equal on both sides. One of these cases forms the subject of our fourth case, the other is detailed by M. Monod. Finally, in the ten other cases the existence of paralysis was ascertained, either simple, or with contraction of the parts deprived of voluntary motion. Out of these ten cases the lesion of motion was observed nine times in the limbs of the side opposite to the hemisphere of the cerebellum, where the softening took place—once it was found to have taken place on the same side as the softening. This exceptional case was published by M. Rostan. It was that of a woman, sixty- three years of age, who entered the infirmary of the Salpitriere to be treated for pneumonia, of which she died. This woman had, for a long time back, the right arm contracted, and could not perform any motion with it; the three other limbs had preserved their natural motion. This paralysis was established gradually, and had been preceded by a numbness which occupied successively the hand, forearm, and arm. The autopsy showed no alteration in the nervous centres except the following :—The lower part of the right side of the cerebellum, near the annular protuberance, presented a depression produced by an exostosis which occupied the corresponding part of the petrous portion of the temporal bone, and of the portion of the occipital which is articulated with it. The substance of the cere- bellum in contact with this exostosis was softened. Is it in consequence of its particular seat, that in this case the softening of the cerebellum gave rise to a paralysis on the same side ; or may it not be asked whether the lesion of the cerebellum was really here the cause of the paralysis, for the vertebral canal was not examined ? Now, might it not have happened that another exostosis was developed on a point of the parietes of this canal, and that by compressing the part of the spinal marrow on the right, it really was the cause of the paralysis of the right side ? In all these cases, besides, the paralysis most frequently attacked the two extremities of one side at once. Sometimes it was established suddenly ; at other times, on the contrary, it commenced by a slight weakening of the limbs, which gradually increased. The paralysis of the extremities was but very rarely accompanied by paralysis of other parts of the body ; once only there was observed a paralysis of the face, which took place on the same side as that of the extremities. How shall this fact be explained in our present knowledge of anatomy. The case was published by M. Lallemand.* The subject of it suddenly lost consciousness : on coming to himself, he had hemiplegia of the right side, and the angle of the commissure of the lips was drawn to the left side. A softening of the white substance of the left lobes of the cerebellum was observed, and no other lesion. * Loc. Cit., Lettre ii. p. 134. 288 ANDRAL'S MEDICAL CLINIC. Strabismus was remarked in only one case : it took place on the side opposite to the softening. The sensibility presented several alterations, but none of them were constant. At first several patients complained of a pain, the seat of which corresponded exactly with half of the lesion; this pain had its seat at the occiput, but it was entirely wanting in more than one case. The cutaneous sensibility presented the same differences as in the case of softening of the cerebral hemispheres ; sometimes it was abolished, and sometimes more acute than usual ; sometimes it con- tinued in its normal state. In the case in which coma existed, the entire skin was insensible; except those cases, the loss of insensibility existed only in the paralysed limbs. Once only that same insensibility of the conjunctiva was observed which is found to exist in cases where the fifth pair of nerves is affected ; at the same time, says M. Lallemand, to whom we are indebted for the knowledge of this fact, the eye was as it were withered.* What bond, then, unites certain fibres of the cerebellum to the fifth pair ? Digestion,circulation,and thedifferentsecretions presented nothing remarkable. In some cases the respiration was very much modified, as may be seen in our fourth case. With respect to the genital organs, there is reference made to one only of the thirteen which form the subject of our analysis. This case was published by M. Dany: the patient, says this physician, continually applied his hand to the testicles, though these organs presented no trace of suffering. In all that has been said, there is as yet mention only of the cases in which one of the lateral lobes of the cerebellum alone was softened. Let us now consider the cases in which the softening affected the entire cerebellum. Only three cases of this kind have been published to our knowledge. In one of these three cases,t the individual, who was a child of fourteen months old, was attacked with epileptic fits, in which he died. During his illness it was noticed that the penis was in a state of half-erection. The cerebellum was softened and diffluent at its base on both sides. But the some softening affected the upper por- tion of the spinal marrow. In the second casef an erotic delirium was observed with the phenomenon of erection. The author of this case states, without more detail, that the grey substance of the cerebellum was every- where softened. Was it only the external grey substance ? In the third case§ phenomena of an entirely different nature took place. The patient evinced an extraordinary tendency to fall back; when he sat down he could not rise without much difficulty ; one * Lallemand, Lettre ii. p. 134. f Revue Medicate, torn. i. p. 338. X Archives Generates de M&tecine, torn. xxii. p. 133. § Journal de Physiologie Experimentale, &c, torn. vi. DISEASES OF THE BRAIN. 289 time when in the erect posture, the first movement of his feet was in a lateral direction, without his leaving the place where he was. In order to change his position, he directed his feet from before backwards : he assured us that an irresistible force obliged him to go backwards. In this case the lesion of the cerebellum was much more considerable than in the two preceding cases ; it was, in its entire extent, changed into a whitish mass, in which there was no longer discovered any trace of organisation. Thus the functional disturbances occasioned by softening of the cerebellum vary7 accord- ing to the greater or less extent of this softening, and to the parts affected. SECTION III. ACCIDENTAL PRODUCTS DEVELOPED IN THE CEREBELLUM. Case 1.—Cyst filled with pus in the centre of the left hemisphere of the cerebellum— Pain at the base of the occiput—Paralysis, with contraction of the extremities of the right side—Convulsions at intervals—Intellect sound. A girl, nineteen years of age, was paralysed in the entire right side of the body, when she was admitted into the Hopital Cochin. The upper paralytic extremity was at the same time very much contracted, and she experienced acute pains in the part from time to time. She also felt, towards the upper part of the nape of the neck, acute lancinating pains, which returned occasionally. In the interval between these she felt towards the same part a dull pain, which seemed to her to lessen when she inclined the head forwards, and a little to the left; she usually kept in this position. She told us that she first began to feel pain in the back part of the head, and that some little time after the extremities of the right side lost the power of motion. All this period amounted to five weeks. The intellect was clear. A little time after her admission, the pains of the occiput and back part of the neck became more and more acute, and convulsive movements soon supervened. These always commenced by a violent shaking of the head, which was inclined backwards, as in a variety of tetanus. On some days the convulsions were confined to this part ; at other times they became general, and almost all the muscles of the body became affected. Consciousness was still preserved. The convulsions still went on increasing both in frequency and intensity ; they extended to the respiratory muscles, and she died in a state of asphyxia. She vomited frequently towards the close. Post mortem.—The left hemisphere of the cerebellum was oc- cupied some lines beneath its upper surface by a cyst as large as a pullet's egg, filled with greenish pus ; the parietes of this cyst, formed of a sort of cellulo-fibrous tissue, were about a line in thick- ness. Around it the nervous tissue was healthy. 290 ANDRAL'S MEDICAL CLINIC. Remarks. — This case of encysted abscess of the cerebellum resembles very much, vvith respect to the symptoms, some cases of softening of the cerebellum detailed above. We find here both the occipital pain and the paralysis, the seat of which is always op- posite to that of the lesion. Here also, as in several of these cases of softening, the mind remained clear. But there is in this case a pre- vailing phenomenon ; that is, the convulsions, the constantly increa- sing intensity of which always ends fatally. The vomiting ob- served towards the close was not connected with any morbid change of the stomach ; like the convulsions, in the nature of which they participated, they were the result of disturbance of the innervation. This abscess formed slowly, and did not succeed to any acute disease, nor was it caused by external violence. Let us now add to this case a notice of some others of abscess of the cerebellum, published by different writers. The cases of this kind which we have been able to collect amount to eleven. In eight of them the abscess occupied one of the lateral lobes of the cerebellum; in two others the suppuration occupied the two lobes ; and in one case only it was the middle lobe that was affected. An analysis of these eleven cases and of our own gives the fol- lowing results :—The mind was not disturbed in any case, except sometimes at the end : in several cases it is said the patients die possessed of all their consciousness. In the individual who forms the subject of one of Dr. Abercrombie's cases, continual drowsiness was observed ; but the patient could be easily aroused from it, and then he enjoyed all his intellect. The power of motion remained entire in six cases. In five of them one of the lateral lobes of the cerebellum was the seat of the abscess ; in the sixth it was the middle lobe. Paralysis took place in three cases, but with particular circum- stances in each of them. Thus, in the case above recorded, there was hemiplegia with con- traction on the side opposite to the diseased lobe of the cerebellum. In another case, quoted by Borsieri from Plancus, there was also hemiplegia, but on the same side as the abscess of the cerebellum.* This case would form the second exception which we meet to the law of the crossing influence of the hemispheres of the cerebellum ; the first exception Was furnished by M. Rostan. In a third case, cited by M. Larrey, the paralysis at first affected the two lower extremities ; and subsequently it became general. * Dextrum cerebelli lobum abscessu magnam partem corruptum vidit Cel. Lanus Plancus Ariminensis in nobili puero, qui a suppresso puns ex aure ejus- dem lateris fluxu, cui a priinis usque annis obnoxius fuit, inciderat in acerrimam cephalalgiam cum febre continua acuta, ex qua intra breve temporis spatium mortem oppetiit. Febris pluries intra diem exacerbatur, et horrifica, erat, sic ut hemitritaeo similis videretur. Accedebat subinde aphonia et trismus sed brevi adibat loquend i potestas. Tandem paralysi non oppositi, ut moris est, sed ejusdem lateris correptus, sensibusque orbatus, futo cessit. DISEASES OF THE BRAIN. 291 In this case the suppuration attacked the two lobes of thecerebellum at once. A remarkable alteration of motion was noticed in M. Lallemand's case. The patient staggered on his legs. In this case, the only one which tends to confirm the opinion of the physiologists, who assign to the cerebellum the province of regulating motion, the cerebellum was converted into a pouch full of pus. To complete the table of the different disturbances of motion, which took place in the twelve cases of abscess of the cerebellum now analysed, we should add, that in the case of Plancus already cited there was a well-marked trismus, and in one of Abercrom- bie's cases, where the abscess occupied but one of the lobes of the cerebellum, strabismus was observed. Such are the different disturbances affecting motion in these twelve cases. Let us now see what were the disorders of sensation. In only one case (and that was seen by ourselves) the limbs, but only those which were paralysed, were the seat of acute pains. In no other case was the sensibility affected. In nine cases there was pain of the head ; and in all it was re- markably severe ; sometimes it was continued, sometimes inter- mittent. Four times the seat of this pain was not determined ; three times it occupied the occipital region ; twice the frontal and occipital regions, alternately in one case, simultaneously in the other ; once it was confined to the anterior part of the head. In only one case was there blindness ; it was in the person seen by Gall, in whom the two lobes of the cerebellum were in a state of suppuration. But Gall adds, that the commissure of the* two lobes of the cerebellum (pons Varolii) was very much atrophied, and of a yellowish colour. Now did not the morbid state of this part involve the fifth pair of nerves ? In nearly half the cases there was observed either nausea or vomiting. These phenomena were not a mere complication ; they were certainly connected with the affection of the cerebellum. The generative functions presented nothing particular, except in one case. It was that recorded by Gall, in which the suppuration attacked the two lobes of the cerebellum. The subject of this case was a boy thirteen years old, who gave himself up furiously to onanism. Among these twelve cases, there are some in which the affection presented the phenomena of its commencement and progress of acute inflammations ; in others, on the contrary, the suppuration took place imperceptibly without the symptoms of an acute affection having been observed at any period. In cases of this latter kind, the duration of the disease was sometimes very long. Case 2.—Tuberculous mass in the left lobe of the cerebellum—pain of the head—Hemi- plegia on the left side—Blindness—Intellect retained. A laceman, aged twenty-nine years, presented the following state: —such a weakness of sight that he could scarcely distinguish day 292 ANDRAL'S MEDICAL CLINIC. from night, and yet considerable contraction of the two pupils; natural sensibility of the face still preserved ; pain all over the head, but more acute towards the occipital region ; hemiplegia of the left side complete, without contraction, or modification of the sensibility of the paralysed limbs. Nothing remarkable in the movements of the tongue; intellect sound ; frequent cough; some dyspnoea ; pale and emaciated ; subject to diarrhoea. He entered La ChariU, where for the first fortnight he complained of nothing additional, except that during this time he had diarrhoea, for which leeches were applied to the anus. He told us that, for about the last three years, he had a very painful headache, intermittent at first, and which subsequently became continued ; he also states that,during this time, he gradually lost the power of seeing, and that of motion in the ex- tremities of the left side ; still further, about two years ago, he continued struck for the space of three months with complete insensibility of all the left side of the face. Then he no longer had any taste for food, and the mucous membrane liningthe interior of the left cheek seemed to be separated, as if by a piece of linen, from the objects brought in contact with it. He always continued to hear equally well with both ears. After a fortnight's stay in the hospital, he was carried off in less than three days by an acute peritonitis. Post mortem.—Cranium.—Nothing remarkable in the cere- brum. But on viewing the cerebellum externally, its right lobe was observed no longer to have its usual form ; it was marked with eminences (bosseW), and its laminae no longer have their ordinary direction, nor their natural relations ; several were effaced. We scarcely penetrated some lines in depth, when in the inner half of this lobe, and in all its height, we find, instead of the tissue which should form it, a hard substance of a yellowish white colour, pos- sessing all the characters of tubercular matter ; there was no soften- ing in any part. Thorax.—Some miliary tubercles were scattered through the two longs. Abdomen.—The peritoneum was filled with a purulent liquid. A great number of small white bodies projected from the mucous membrane of the ileum, and resembled so many tubercles. Small ulcerations were found towards the end of this intestine, one of which established a communication between the interior of the in- testinal canal and the peritoneum ; whence the peritonitis. The spleen also contained some tubercles. Remarks.—A pain, the principal seat of which was in relation with that of the lesion ; paralysis which took place on the side of the body opposite to the latter ; and the loss of sight: such were the symptoms accompanying in this case the development of the tuber- cular matter in one of the lateral lobes of the cerebellum. They are the same symptoms as those occasioned by the different affections of the cerebellum already described, only here they are developed very slowly, and continue much longer. In the midst of all this dis- DISEASES OF THE BRATN. 293 turbance the intellect remained undisturbed. With respect to the extraordinary loss of sensibility, observed for the space of three months in the left side of the face, and which was accompanied by the complete abolition of the sense of taste, could this have been occasioned by a temporary affection of the fifth pair of nerves ? There were tubercles in several other organs also, as well as in the cerebellum. Those contained by the lung confirm the law laid down by M. Louis. Case 3.—Several tubercles in the right lobe of the cerebellum—Occipital headache— Vomiting—Pulmonary phthisis. A man, twenty-three years of age, entered La ChariU, with the ordinary symptoms of pulmonary phthisis already far advanced. This man was also tormented for more than a year by a fixed pain seated in the occiput, more particularly towards the right side of this bone. This pain, which was usually dull, became occasionally very acute. Besides, the patient for some months back was annoyed with vomiting, which was frequently repeated; this vomitingalways came on whenever the headache became more intense ; it returned even without such a precursor ; appetite tolerable ; no pain in the epigastrium; appearance of the tongue natural; diarrhoea. He died of phthisis, without presenting any new symptoms referrible to the nervous centres. Post mortem.—Five tubercles in the right lobe of the cerebel- lum, three of which were of the size of a common pea, another that of a large nut, and another that of a chestnut at least. None of them were softened ; between them the tissue of the cerebellum was healthy ; two of these tubercles were situated near the upper surface of the organ, and the others were developed in the very centre of the lobe of the cerebellum. Thorax.—Cavities and numerous tubercles in the two lungs. Abdomen.—Stomach healthy ; ulcerations in the intestines. Remarks.—Very different from the preceding, this case presents to us an instance of tubercles of the cerebellum announced by very few symptoms. The pain of the head is the only phenomenon, the long and continued existence of which announced a lesion of the encephalon ; motion remained perfectly entire. The vomiting we think connected with the disease of the cerebellum. On the one hand, no lesion of the stomach accounted for it, and on the other hand, we have seen this same symptom supervene in several other cases of disease of the encephalon in general, and of the cerebellum in particular. We have even seen cases in which, either for the entire duration of the disease, or in some of its periods, vomiting was the only phenomenon which we could connect with the cerebral affection, so that the latter, leaving sound the different functions of the life of relation, confined itself exclusively to the stomach, whose action itdisturbed. Dr. Abercrombie was so struck by the frequency of this occurrence, that in his treatise on Diseases of the Brain, he has ranged under a particular head a certain number of cerebral Oct. 1838.—A" 27 294 ANDRAL'S MEDICAL CLINIC. affections of a very different nature, but which all resemble each other in this, that the prevailing symptoms to which they give rise are referrible to the digestive organs. There are cases also where these symptoms are quite concealed, where the headache itself does not show itself, and in which there are discovered in the cerebellum tubercles more or less numerous, without there having existed during life any disturbance on the part of the nervous centres ; similar cases are not rare, particularly in children. We have met with a case of a boy ten years old, who died of phthisis, and who never complained at all of the head, yet the left lobe of the cerebellum contained four tubercles. These cases remind us of another which was very remarkable, and in which no symptom was observed on the part of the nervous centres, though an important part of them was the seat of a well- marked cancerous degeneration. The subject in this case was a woman forty years of age, who died of cancer of the uterus, without having ever presented any symptoms but such as usually attend this affection ; the cancer was confined to the neck of the uterus. The portion of the medulla oblongata forming the anterior wall of the fourth ventricle, and which constitutes the posterior part of the great commissure of the cerebellum, immediately behind the tubercula quadrigemina, and as far as the anterior extremity of the corpora restiformia, was changed into a tissue similar to that occupying the neck of the uterus. Case 4.—Extraordinary sensibility of the skin of the trunk and extremities—Para- lysis of one of the sides of the face—Two tubercular masses, one of which was seated in the left lobe of the cerebellum and the other in the vertebral canal—Pul- monary phthisis. A boy, seventeen years of age, presented all the signs of pulmonary phthisis, when he was received into La ChariU. He also exhibi- ted some symptoms which indicated a serious lesion of the nervous system. His state was as follows:— Habitual retroversion of the head; it could, however, be easily brought forward, but if left to itself it soon resumed its former position. The extremities retained all their freedom of motion; the senses were sound ; but the moment any point of the skin was touched, whether of the limbs or trunk, he experienced a very painful sensation; all the motions of the arms and legs were accompanied with a sort of pain, which the patient compared to that which is felt when one is fatigued. All the left side of the face was struck with the most complete immobility; neither the cheek, eyebrow, nor skin of the forehead on this side could be at all moved, and the right commissure of the lips was drawn up very much. The left eye always open, could not be shut at the will of the patient; the consequence of this was redness of the conjunctiva of this side ; these different symptoms existed for several months in all the paralysed side ; the sensibility was retained. This patient died in the course of a pulmonary phthisis, without DISEASES OF THE BRAIN. 295 having presented any new phenomenon on the part of the nervous system. Post mortem.—Cranium.—The sub-arachnoid cellular tissue was infiltrated with a certain quantity of limpid serum ; this same serum filled the ventricles; the left lobe of the cerebellum was occupied, not far from its outer edge, and at nearly an equal distance from its upper and lower surfaces, by a tubercle about as large as a nut—this tubercle was not softened. On the level of the first and second cervical vertebrae, the spinal marrow was separated from the vertebrae by a tubercular mass developed in the meninges, not large enough, however, to make any considerble pressure on the spinal marrow. The lungs contained numerous tubercles in all stages. The intestines were ulcerated. Remarks.—Here again was a case in which a small tubercle, developed in the cerebellum, remained completely latent. There were, in fact, but two symptoms which indicated an affection of the nervous system: the first was the facial paralysis, and the second the cutaneous hyperesthesia,* accompanied with pain in muscular contraction. Now the paralysis of the left side of the face does not seem to us to have been caused by the alteration of the cere- bellum, but, perhaps, by an affection of the portio dura of the seventh pair of nerves. Perhaps there was also a tubercle, which, developed in the bony canal in which this nerve is inclosed, had made pressure on it. With respect to the great increase of sensibility exhibited by the skin of the trunk and limbs, and the pain whilst the muscles of these limbs were contracting, it seems to us a matter of doubt whether this phenomenon depended on the lesion of the cerebellum. We are well aware that some cases have been cited in which the changes of this organ have been followed by similar phenomena. Here, besides, there was another lesion, which, in our opinion, was more probably the cause of the extraordinary exaltation of the sen- sibility ; that was the tubercular mass developed between the upper extremity of the spinal marrow, and the posterior wall of the bony canal inclosing it. It pressed against the posterior surface of the spinal marrow, that is, the part of this organ which the experiments of M. Magendie warrant us in regarding as the special agent of sensi- bility. But if the tubercular mass had increased, a time would have arrived when it would have compressed the spinal marrow, instead of irritating it by its mere contact; and then the sensibility, at first exalted, would have been destroyed. Case 5.—A cyst filled with ossiform concretions in the right lobe of the cerebellum. A female child, twenty months old, exhibited no other symptom during her stay in the Hopital des Enfans, than a constant moving * Hyperesthesia, excessive sensibility, from mt^, and Mo-SxvofAou, to feel or per- ceive.—Tr. 296 ANDRAL'S MEDICAL CLINIC. of the head, by which this part was continually balancing from right to left and from left to right. In other respects the child seemed to evince as much intelligence as other children of the same age ; her sight was good, and the motions of the limbs free ; countenance pale. She died of severe diarrhoea. Post mortem.—The centre of the right lobe of the cerebellum was occupied by a cyst the size of a nut, which contained a great number of small concretions of irregular forms, and hard as bone : they were immersed in a gelatinous kind of liquid : around them the nervous substance underwent slight softening. Several of the convolutions of the convexity of the cerebral hemispheres were considerably hardened. Remarks.—A considerable number of cases have been recorded relative to tumours of different kinds developed in the cerebellum and around it,and which,in either situation, must exercise an influence on the functions of this organ, whether it be irritated, compressed, or disorganised by them. We have found scattered, in different works, thirty-one cases of this kind. In all these cases, the tumours formed in the cerebellum or in its membranes, were sometimes cysts containing solid or liquid substances of different kinds, sometimes fibrous masses, sometimes tubercular or cancerous products. In the great majority of these cases, the mind was preserved during the entire course of the disease; only that frequently a few days before death, a state of coma was observed, which sometimes might be accounted for by considerable injection of the entire encephalic mass, or by the presence of a great quantity of serum in the ventricles. Sometimes no lesion was found which could account for it; in the latter case it is probable that a moment arrives, when, either by its greater development, or by the fact of its prolonged existence, the affection of the cerebellum will produce a reflected effect on the rest of the encephalon, and seriously disturbs its func- tions ; for there is certainly a consent of action between all the parts of the encephalon, and one of them cannot be for any time altered without the others ultimately feeling it. Seven patients only, out of thirty-six, presented long before death a marked disturbance of the intellect. One of these patients, a female, thirty-five years of age, was an idiot from birth. The right lobe of the cerebellum was compressed by a tumour which had its origin in the occipital fossa. It might be supposed that the idiocy was caused by the embarrassment of the cerebral circulation ; but, is it probable that this tumour existed from birth ? Now, the absence of mind was dated from this period. It is not, then, probable that, in this case, the lesions found in the cranium were the cause of the idiocy. Another patient exhibited a loss, at first temporary, but after- wards permanent, of the memory of words. There was found in this individual an encephaloid tumour in the centre of the right lobe of the cerebellum, nearer the lower than the upper surface. A great quantity of serum also distended the lateral ventricles. DISEASES OF THE BRAIN. 297 In three other patients, a general weakness of intellect was noticed. In one of them the right lobe of the cerebellum was compressed by a tumour which belonged to the dura mater; some serum dilated the ventricles. In the second an encephaloid mass seized on the posterior and inferior part of the cerebellum, as well as the medulla oblongata. In the third, a tubercle of an inch and a half in diameter was developed on the upper surface of the cerebellum, in the median line. In a seventh patient some delirium was observed. Did this delirium, which was of short duration, depend on the tubercles found in the left lobe of the cerebellum ? Was it not rather the result of the injection which was detected in the pia mater of the base of the brain ? These are the only cases in which the mind presented any perceptible disturbance. The disturbances of motion are much more frequent. Out of our thirty-six cases there are but eight in which motion was not in some way disturbed. Complete or incomplete paralysis was observed fifteen times. In this number there were but four who had hemiplegia ; it took place on the side opposite to the lesion of the cerebellum in three cases, and in a fourth the two lobes were diseased. Paralysis was also observed four times. In these four cases the cerebellum was compressed or disorganised, either in its two lateral lobes at once, or in its middle lobe. In one of these cases the medulla oblongata participated in the alteration of the cerebellum. It is remarkable that in these four cases the paralysis particularly affected the lower extremities, whilst the upper ones enjoyed all their freedom of motion, or else had undergone only a debility which was always less than the lower extremities. Two patients presented a paralysis, or at least a considerable debility of the four limbs. In one of them, a tubercular mass, developed at the base of the cranium, compressed at once the cere- bellum and spinal marrow ; in others the two lateral lobes of the cerebellum contained tubercles, but they were twice as large in the right lobe as in the left; and the feebleness of the limbs was greater on the left than on the right; so that this case of general paralysis may again serve to prove the crossing influence of the lobes of the cerebellum. The paralysis of the face, which we met once in one of our own cases, isolated from every other paralysis, was connected with the existence of two tuberculous masses ; the one developed on the left lobe of the cerebellum, and the other at the posterior surface of the spinal marrow. There remain four patients, of whom nothing else is said with respect to motion except that they gradually become debilitated. Involuntary contractions affecting a greater or less number of muscles were observed more frequently than paralysis ; we met twenty-two cases in which these contractions were found to exist. In fifteen of these twenty-two cases, the entire body was agitated at 298 ANDRAL'S MEDICAL CLINIC. intervals by convulsive movements, which became more and more frequent, and it was often in the midst of violent convulsions that the individuals died. Some, and that was the greatest number, retained their consciousness during the continuance of their convul- sions ; others lost it suddenly, and they presented the symptoms which characterise an attack of epilepsy. In these patients, the lesionjoceupied different seats ; sometimes confined to a single lobe of the cerebellum, sometimes extending to the two, sometimes occupy- ing also the medulla oblongata. The movements of the tongue were embarrassed in only two cases, and in both it results from the seat of the lesion, that the nerve of the ninth pair must be compressed or disorganised by the tumor pressing on the cerebellum. In the thirty-six cases which form the subject of our analysis, the sensibility presented disturbance not less varied than the power of motion. The general sensibility presented no disturbance in the greater number of cases: sometimes, however, it exhibited a remarkable exaltation, whilst, at other times it was completely abolished. Not merely has the general sensibility been modified in some of our thirty-six patients ; occasionally, also, the organs of the particular senses have been found affected ; thus, in one case, deafness was observed ; and in six, vision was either completely destroyed, or very much weakened. Among the organs of nutritive life, the stomach is the only one which presented a phenomenon deserving of particular notice, with respect to its frequent reproduction ; this phenomenon is vomiting; it was observed twelve times in thirty-six cases. If we now consider these twelve cases with respect to the nature and seat of the disease of the cerebellum, we will find nothing dif- ferent from what was to be seen in the twenty-four other cases, where there was neither vomiting nor nausea. A priori we should not expect to find this peculiarity of either seat or lesion ; for throughout this volume, in connexion with lesions the most different, as well those of the meninges as those of the nervous pulp itself, we have seen vomiting show itself as a common effect of a crowd of affections of the encephalon. Can it be said, that when it is produced the brain is in the same condition as when it does not occur ? Certainly not, for a different effect cannot occur from a different cause; but these conditions we know not; they escape us just as those in- ternal changes of organisation have been removed hitherto from our researches. Certainly, the inconstancy of the effects here can only be owing to the variety of causes. To ascertain those causes, it would be necessary to interrogate each cerebral fibre, first considered separately, and then traced in its connexions with other fibres. It is in this double point of view, that we think the pathology, as well as the physiology of the brain, should be studied. It is, on the one hand, a great whole, composed of a number of parts, each of which performs a special act; but, on the other hand, these different parts DISEASES OF THE BRAIN. 299 are intimately connected with each other, so that they are mutually bound together. Hence it follows, that in the point where a lesion is discovered, the direct cause of the effects which it produces does not always reside, and according as it re-acts on such or such other points especially destined for the performance of a certain act, it is this which will be found modified. If then it happened that we suc- ceeded in discovering in the encephalon a certain number of parts, the lesions of which always occasioned the disturbance of the same cerebral act, it would not, in our opinion, be fair to object to the doctrine of localisation, that there are also other cases where this same functional disturbance is reproduced, though the lesion might be elsewhere. Among the thirty-six cases constituting the subject of our analysis, only in three was any thing particular noticed with respect to the genital apparatus. In one of these cases permanent erection of the penis was observed during the whole time. There was, in this case, compression made at one and the same time, by a tuberculous mass, both on the right lobe of the cerebellum, and on the medulla ob- longata. In the second case the patient indulged in masturbation ; several tubercles were found in the upper part of the cerebellum ; whether on both sides, or on one only, we are not told. Lastly, in the third case, regarding an individual said to be very prone to venereal desires, a tubercular mass occupied all the substance of the middle lobe. THE END.