'.'*!afif*^5»;i» Vr- *tf rv /*-.* w :<*•, a? &kv*: :« V ML . . , -;-; n. ) UCQ'OQC'QTyOOi Surgeon General's Office TW /V),'-J Vu$F'}- i£3Ki»®f .& hen, N ^J^?/ S*^ 3CGffC/u( v • ■ • ^ *€^fe»s. %:■' ■■ ■ W l& -3b- t^9 ibs^* jefe^ il ■pv.'^l I BENJfAlvn^" DRAKE, I PATHOLOGICAL PRACTICAL RESEARCHES DISEASES OF THE BRAIIV THE SPINAL CORD. PATHOLOGICAL PRACTICAL RESEARCHES DISEASES OF THE BRAIN v. AND THE SPINAL CORD. ____UL BY JOHN ABERCROMBIE, M.D., FELLoV OF THE HOYAE COLLEGE OF PHYSICIANS OF EDINBURGH, &.C., AND FIRST PUISICIAN TO HIS MAJESTY IN SCOTLAND. FIRST AMERICAN FROM THE SECOND EDINBURGH EDITION, ENLARGED. ■r cfsXS v: CO CAREY & LEA. 1831. Ai't+P QBIGGS & DICKINSON, PRINTERS. PREFACE TO THE FIRST EDITION. It is a matter of the utmost delicacy for a phy- sician to obtrude upon the profession his general statements, in regard either to the phenomena of disease, or the action of remedies. The value of such statements does not depend upon his veracity only, but must likewise rest, in a very great degree, upon the character which he bears as a philosophi- cal observer, and the extent of the observations on which his conclusions are founded. Hence, arises the hesitation with which we receive all general statements, when made by persons with whose op- portunities of observation and habits of induction we are not acquainted; and the importance which we attach to a simple record of facts, in a concise and accessible form, apart both from hypothesis and system. The author of such a record contributes that which has a fixed and certain value, depend- ent only upon his correctness in distinctly describing what he has seen; and thus is furnished a series of facts which every practitioner may study for him- VI PREFACE. self, and from which he may acquire a knowledge of phenomena, and of their relations to each other, nearly in the same manner as he does from his own observation. In the revolutions of medical science, there has been, for some years, a progressive and remarkable change of opinion, in regard to the mode of con- ducting medical investigations. There appears to have been a tacit but very general admission of the fallacy of medical hypotheses, and the precarious nature of general principles in medicine; and there seems to be an increasing conviction of the indis- pensable necessity, of founding all our conclusions in medical science, upon an extensive and accurate acquaintance with the pathology of disease. The facts which are required for this purpose can be derived only from the contributions of practical men; and it is of the utmost consequence that such persons should extensively record their observa- tions, as these must form the only basis on which can be founded any legitimate principles in medical science. i General principles in physical science are nothing more than general facts, or facts which are com- mon to all the individuals of a particular class; and it is only when they arc deduced from a correct ex- PREFACE. Vll amination of all these individuals, that they can possess either truth or utility. When they have been framed from a limited observation, they are, in general science, useless, and in medicine, dan- gerous; and in regard to medical science we may perhaps venture to assert, that the purposes of prac- tical utility are promoted in almost an equal degree, when a principle which has been proposed is con- firmed by the progress of observation, and when one which has been received upon inadequate grounds is shown to be fallacious. Influenced by these considerations, the author of the following treatise has, from time to time, sub- mitted to the profession a series of researches, on various important subjects, of a pathological and practical nature; and he now intrudes upon their attention with farther observations, in a more con- nected and more extended form. In doing so, he has no system to support, and no new doctrines to propose. He may indulge in conjectures, but these he will keep entirely distinct from the facts upon which they are founded. He assumes no higher character than that of a faithful relater of facts, which a practice of considerable extent has brought under his view; and he aspires to no higher merit, than to contribute something towards enlarging our acquaintance with the phenomena of disease. Vlll PREFACE. This volume is divided into four parts. The three first of these refer to diseases of the Brain, arranged under three classes, the Inflammatory, the Apoplectic, and the Organic. This arrange- ment will probably answer every practical purpose; for, though the affections of the inflammatory class generally terminate by an apoplectic state, or a state of coma, and the organic affections are often distinguished by apoplectic paroxysms, yet, in a pa- thological point of view, the classes appear to be sufficiently distinct, for the purpose of an arbitrary division of the subject. The fourth part refers to the diseases of the Spinal Cord and its membranes; and, in an appendix to this part, a slight outline is given of the present state of our knowledge in re- gard to the pathology of Nerves. PREFACE SECOND EDITION. The Author deeply feels the approbation which the profession have been pleased to bestow on the mode of investigation to which he has devoted him- self; and in preparing a new edition of this work, he has been anxious to render it more worthy of their attention. The new matter that is added to this edition, consists chiefly of the following cases and the ob- servations connected with them :—Cases 18. 30. 31. 82. 91. 94. 111. 114. 115. 133. 140. 146. 151. 152. There are also some additional facts and observa- tions on diseases of the nerves, beginning at page 441. Edinburgh, July, 1829. 2 CONTEXTS, PART I. Page OF THE INFLAMMATORY AFFECTIONS OF THE BRAIN.......23 SECTION I. GENERAL VIEW OF THE SYMPTOMS INDICATING IN- FLAMMATORY DISEASE WITHIN THE HEAD . 26 SECTION II. OF THE PRINCIPAL SEATS AND TERMINATIONS OF THE DISEASE ....... 39 Seats.......39 1. Dura Mater. 2. Pia Mater and Arachnoid. 3. Substance of the Hemispheres. 4. Dense Central Parts—Fornix, Septum, &c. Terminations.......29-46 1. Fatal in the Inflammatory Stage. 2. Serous Effusion. 3. Deposition of False Membrane. 4. Suppuration. 5. Ramollissement, or Softening of the Cerebral Sub- stance. 6. Thickening of the Membranes, &c. Xll CONTENTS. SECTION III. Page INFLAMMATION OF THE DURA MATER the 48 48 51 60 61 64 65 Idiopathic....... Connected with Disease of the Ear and Caries of Temporal Bone with Disease of the Nose with Caries of the Bones of the Cranium with Obliteration of the Lateral Sinus Chronic, with remarkable Thickening SECTION IV. INFLAMMATION OF THE ARACHNOID AND PIA MATER, OR MENINGITIS ......67 § 1. Simple Meningitis in the most common Form . 69 § 2. Meningitis of very great Extent, with Obscure Symptoms......72 § 3. Meningitis of very small Extent, with Severe Symptoms ......74 § 4. Meningitis of the Base.....75 § 5. Meningitis with Suppuration on the Surface . 76 § 6. Meningitis with Suppuration in the Ventricles . 77 § 7. Meningitis of the Cerebellum ... 78 § 8. Of a very dangerous Modification of the Disease which shows only increased Vascularity . 80 SECTION V. INFLAMMATION OF THE SUBSTANCE OF THE HEMI- SPHERES ........90 § 1. Fatal in.the Inflammatory Stage . . . 9] § 2. The Affection in a Chronic Form ... 95 § 3. The inflamed Mass passing into Ramollissement 98 § 4. Extensive Ramollissement of the Corpus Straitum 102 CONTENTS. Xlll Page § 5. The Affection in a Chronic form, with Ramol- lissement of small extent, and remarkable symptoms ......104 § 6. The Affection in a Chronic form, with exten- sive Ramollissement and Remarkable Disease of the Basilar Artery . . . .107 § 7. Ramollissement combined with Suppuration . 109 § 8. Undefined Suppuration . . . .110 § 9. Extensive Undefined Suppuration with Extrava- sated Blood......112 §10. The Encysted Abscess . . . .113 § 11. Abscess of the Corpus Striatum of very small Extent.......120 § 12. Abscess of the Medulla Oblongata . . 121 §13. Abscess of the Cerebellum .... 122 §14. Ulceration of the Surface of the Brain . . 124 General Review of the Subject . . .125 SECTION VI. INFLAMMATION OF THE CENTRAL PARTS—CORPUS CALLOSUM, FORNIX, SEPTUM LUCID UM, AND THE MEMBRANE LINING THE VENTRICLES . . 142 § 1. Inflammation of the Membrane lining the Ventri- cles ....... § 2. The Inflammatory Origin of the Ramollissement of the Septum Lucidum . . . . § 3. Ramollissement of the Central Parts, Fatal with- out Effusion ...... § 4. Ramollissement of the Central Parts, combined with Serous Effusion, constituting the most common form of Acute Hydrocephalus Cases illustrating some important Varieties in the Symptoms . . . . ■ . The Affection occurring in Phthisical Cases § 5. Cases of Simple Effusion .... 145 146 147 150 152 159 161 XIV CONTENTS. Page General Review of the Subject . . .164 SECTION VII. CAUSES OF THE INFLAMMATORY AFFECTIONS OF THE BRAIN ......167 1. Febrile Diseases . . . ■ • .167 2. Injuries . . . . . • .168 3. Suppressed Evacuations ..... 169 4. Appearing in Connexion with other Chronic Dis- eases ......♦• 5. Passions—Stimulating Liquors—Heat of the Sun, &c.........172 SECTION VIII. TREATMENT OF THE INFLAMMATORY AFFEC- TIONS ........173 Examples of Successful Cases under various Forms 176 170 APPENDIX TO PART I. SECTION I. OF TUBERCULAR DISEASE OF THE BRAIN . , J 83 SECTION II. OF CERTAIN AFFECTIONS OF THE BONES OF THE CRANIUM.......199 SECTION III. OF CERTAIN AFFECTIONS OF THE PERICRANIUM . 211 CONTENTS. XT PART II. OF THE APOPLECTIC AFFECTIONS. Page General View of the Subject . . . . 217 General View of the Symptoms, referred to Three Classes 221 SECTION I. OF THE CASES OF THE FIRST CLASS OR THOSE PRIMA- RILY APOPLECTIC .... 224 § 1. Apoplexy without any Morbid Appearance, or Simple Apoplexy . . . .225 $ 2. Apoplexy with Serous Effusion . . 229 Extensive Effusion without any Apoplectic Symp- toms ..... 232 Of the term, Serous Apoplexy . . 233 Conclusions from a Review of this Part of the Subject . . . . . 235 SECTION II. OF THE CASES OF THE SECOND CLASS, OR THOSE WHICH BEGIN WITH A VIOLENT ATTACK OF HEADACH, AND PASS INTO APOPLEXY GRADUALLY . # m 236 § 1. The Coma rapidly supervening on the First Attack 239 § 2. An interval of perfect recollection for several hours, betwixt the Attack and the Occurrence of Coma 240 § 3. An interval of three days between the Attack and the Occurrence of Coma .... 243 § 4. The fatal Coma occurring a fortnight after the First Attack.......244 § 5. Two distinct Extravasations . . . 245 XVI CONTENTS. Page § 6. The Extravasation confined to the Third and Fourth Ventricles, with remarkable Disease of the Arte- ries of the Brain.....247 § 7. Extravasation on the Surface of the Brain . 248 § 8. Extravasation in the Cerebellum . . . 252 § 9. Extravasation in the Substance of the Tuber Annulare 253 § 10. Extravasation in all the Ventricles, and along the whole course of the Spinal Cord . . 255 Review of the Subject, and of the various Sources of the Haemorrhage in Cases of this Class 257 Of Disease of the Arteries of the Brain 258 Similar Disease of the Veins . . . 260 SECTION III. OF THE CASES OF THE THIRD CLASS, OR THE PARALY- TIC CASES.......262 § 1. Paralysis with Serous Effusion, or with slight Morbid Appearances ...... 264 § 2. Paralysis with Extravasation of Blood of small extent 268 Progress of these Cases—Formation of a Cyst—and Absorption of the Coagulum . . . 270 A. The Cyst empty—the patient dying of another Disease .... 272 B. The Cyst empty—the Patient dying of a fresh Attack .... 277 C. Two Gysts empty—the Coagulum partly absorbed from a Third—the Patient dying of a fresh Attack . . . 279 D. The Cyst on the Surface . . 280 § 3. Paralysis with Ramollissement . . . 283 § 4. Paralysis with Inflammation and its Consequences 288 General Observations on Paralysis . . 289 GeneralP^ " ology of Paralysis . . 290 CONTENTS, XV11 Page SECTION IV. OUTLINE OF THE TREATMENT OF APOPLEXY . 301 APPENDIX TO PART SECOND. CONJECTURES IN REGARD TO THE CIRCULATION IN THE BRAIN......313 PART HI. OF THE ORGANIC DISEASES OF THE BRAIN 327 1. Tumours formed by thickening of the Membranes, &c. 327 2. Deposition of Albuminous Matter , . . 327 3. Dense White Tumour, apparently not Organized 328 4. Flesh-coloured Organized Tumour . . . 328 5. Tubercular Disease .....329 6. Induration of the Cerebral Substance . . . 329 7. Ossifications ....... 329 8. Hydatids .......330 OUTLINE OF THE SYMPTOMS REFERRED TO SEVEN CLASSES. 1. Headach, without any other remarkable Symptom 331 2. Headach, with Affections of the Senses . . 333 3. Headach, Affections of the Senses, Convulsion . 334 4. Convulsion, without Affections of the nenses . 334 5. Cases with Paralysis . . . 335 XVI11 CONTENTS Page 6, The Prominent Symptoms in the Stomach 336 7. Cases with Slight and Transient Apoplectic Affections 337 PART IV. OF THE DISEASES OF THE SPINAL CORD AND ITS MEMBRANES . . . . 341 SECTION I. MENINGITIS OF THE CORD .... 343 SECTION II. INFLAMMATION OF THE SUBSTANCE OF THE CORD 351 § 1. Fatal in the Inflammatory stage . . . 351 § 2. Ramollissement of the Cord .... 352 § 3. Undefined Suppuration . . . .368 § 4. Abscess ....... 370 SECTION III. SEROUS EFFUSION IN THE SPINAL CANAL . . 371 SECTION IV. SPINAL APOPLEXY ...... 374 SECTION V. THICKENING AND FUNGOID DISEASE OF THE MEMBRANES, AND FUNGUS OF THE CORD ITSELF . , 377 SECTION VI. INDURATION OF THE SPINAL CORD . . . 380 CONTENTS. XIX Page SECTION VII. NEW FORMATIONS COMPRESSING THE SPINAL CORD 381 SECTION VIII. DESTRUCTION OF A PORTION OF THE SPINAL CORD 385 SECTION IX. CONCUSSION OF THE SPINAL CORD • - 336 SECTION X. OF CERTAIN AFFECTIONS OF THE BONES OF THE SPINE.......393 SECTION XI. CONCLUDING OBSERVATIONS ON THE PATHOLOGY OF THE SPINAL CORD, WITH REFERENCE TO VA- RIOUS ANOMALOUS AFFECTIONS • • 404 APPENDIX TO PART IV. OUTLINE OF THE DISEASES OF NERVES • • 429 SELECTION OF CASES ILLUSTRATIVE OF THE ORGANIC DISEASES OF THE BRAIN, BEING A SUPPLEMENT TO PART HI........ PATHOLOGICAL AND PRACTICAL RESEARCHES ON DISEASES OF THE BRAIX AND THE SPINAL CORB. DISEASES OF THE BRAI1Y, &c. PART I. OF TUB INFLAMMATORY AFFECTIONS OF THE BRAIN. Peculiar difficulties attend the investigation of inflam-' matory affections of the brain. In the inflammatory diseases of other organs, we are generally able to trace the proper symptoms of the inflammation through the whole course of the disease, and to make allowance for any incidental combi- nations by which they may be modified; but from the rapid effects which all acute diseases of the brain prodace upon the sensorial functions, the patient generally becomes, at an early period, unable to express his feelings, and the proper symp- toms of the disease are lost amid that suspension of all the faculties to which we give the name of oppression of the brain. Whenever this remarkable condition occurs, it naturally becomes the prominent object of attention; and, as it has 24 INFLAMMATORY AFFECTIONS been by long established usage strongly associated with the idea of pressure upon the brain, the investigation has gene- rally been directed to the discovery of a compressing cause. Effused fluid having been found, upon examination after death, in a great proportion of the cases referred to, has on this principle been considered as explaining the symptoms, and here probably the investigation has closed. This course of inquiry seems to have been the occasion of much of that obscurity which so long involved the pa- thology of affections of the brain, particularly the pathology of acute hydrocephalus. More extensive acquaintance with the phenomena of this class of diseases has shown us that the course was fallacious, and has enabled us to ascertain prin- ciples of the utmost praqtical importance. We have learn- ed that the condition which we denominate coma, with its usual concomitant symptoms, is not characteristic of any one condition of the brain, but that it may exist in connexion with diseases which are very different, or even opposite in their nature; that it does not prove the existence of any compressing cause, and particularly that it has no necessa- ry connexion with effusion in the brain; farther, that effu- sion to a great extent may exist in the brain, without pro- ducing any of the symptoms which have usually been as- cribed to it, and, in particular, that these may all exist in connexion with a state of disease which is simply inflam- matory. Following the light thus obtained, we find in the phenomena accompanying inflammation of the brain and its membranes, a subject of much interest and great extent, and one which leads to results of the highest practical va- lue. When applied to the pathology of the disease com- monly called acute hydrocephalus, the importance of this investigation is particularly apparent. For I think we may now consider it as ascertained, that this formidable malady is not a mere dropsical affection of the brain, but an inflam- matory disease, terminating by effusion; that many of OF THE BRAIN. -' 25 the leading symptoms are not connected with the effusion, but with the inflammatory condition which goes before it; and that without any effusion it may be fatal, with all the symptoms which have usually been considered as charac- teristic of hydrocephalus. When we enter more particularly upon this inquiry, we find inflammatory disease in the brain varying considerably in its characters in different cases. These varieties appear to be referrible to three circumstances;—the seat of the in- flammation—its degree of activity—and the mode of its ter- mination. It may be seated in the Dura Mater, the Pia Mater, the Arachnoid, the substance of the Hemispheres, or the deep-seated central parts of the brain. In its activi- ty, it varies from the highest degree of active inflammation to the chronic or scrofulous inflammation with the lowest degree of activity, and with numerous modifications by which the different forms pass into one another by almost insensible gradations. It may terminate by serous effusion, by the deposition of false membrane, by suppuration, or by the ramollissement of the cerebral substance. The pheno- mena resulting from these several varieties, present to us a field of investigation of great extent and considerable diffi- culty. But before entering upon the inquiry, it will be ad- visable to take a general view of the symptoms which indi- cate inflammation of the parts within the head. 26 INFLAMMATORY AFFECTIONS. SECTION 1. GENERAL VIEW OF THE SYMPTOMS WHICH INDICATE INFLAMMATORY DISEASE WITHIN THE HEAD. Our knowledge of this subject is not sufficiently matured to enable us to say with confidence what symptoms indicate inflammation of the substance of the brain, as distinguished from inflammation of its membranes; but the distinction is not of much practical importance, and our present purpose will be answered by a general view of the symptoms which indicate inflammation of any of the parts within the crani- um. They appear under a variety of forms, depending probably, either upon the activity of the disease, or the particular part which is the seat of the inflammation. The leading modifications, as they occur to us in practice, may be referred to the following heads. I. As the first form of the disease, perhaps we ought to place the Phrenitis of systematic writers. It is characterized by fever, watchfulness, acute headach, impatience of light, suffusion of the eyes, and maniacal delirium. This affec- tion, however, is seldom met with as an idiopathic disease; except in a few cases in which it is brought on by the abuse of strong liquors, and in warm climates by exposure to the intense heat of the sun. As a symptomatic affection, it is met with occasionally in fever, and in mania; and a condition nearly allied to it sometimes occurs after injuries of the head. Circumstances will be afterwards mentioned, which render it probable that in this form of the disease the inflam- mation is primarily seated in the membranes of the brain. When fatal, it is generally by a rapid sinking of the vital SYMPTOMS. 27 powers supervening upon the high excitement, without pro- ducing much disorganization of the parts which appear to have been the seat of the disease; for the cases which are referrible to this class, when they terminate fatally, are ge- nerally rapid in their progress, and the appearances on dis- section are often unsatisfactory. There is an affection of frequent occurrence, which perhaps may be referred to this head: It is characterized by a peculiar abberration of mind without any complaint of pain. There is a remarkable restlessness, quickness and impatience of manner, obstinate watchfulness, and incessant rapid talking, the patient ram- bling from one subject to another, with little connexion, but often without any actual hallucination. He knows those about him, and generally answers distinctly questions that are put to him. There is a rapid pulse, but without the other symptoms of fever; and the disease is apt to be mis- taken by a superficial observer for mania, and consequent- ly to be considered as not being attended with danger. But it is an affection of great danger, and is often very rapidly fatal. The nature of it is obscure, and the appearance on dissection is rather unsatisfactory; it consists chiefly of a highly vascular state of the Pia Mater, without any actual result of inflammation. II. In a second form of the disease, which is worthy of much attention, the first symptom that excites alarm is a sudden attack of convulsion. This in some cases occurs without any previous illness; in others it is preceded by slight complaints which had attracted little attention;—in one case which will be described, it was preceded by vo- miting, in another by slight headach for several days. The convulsion is generally long and severe; in some cases it is followed immediately by coma, which in a few days is fa- tal; in others, the convulsion recurs frequently at short in- tervals, the patient in the intervals being sensible and com- plaining of headach, and after twelve or twenty-four hours, 28 INFLAMMATORY AFFECTIONS. passes into coma. Sometimes after the coma has continued for a certain time, perhaps for twelve hours, there is a com- plete recovery from it; and for several days the patient ap- pears to be in the most favourable state, when, without any warning, the convulsion returns, and terminates in fatal coma. In a very interesting modification of this form of the disease, the convulsion is confined to one side of the body, or to one limb, and is usually followed by paralysis of the part affected; and in some cases, the first symptom is a sudden attack of paralysis without the preceding con- vulsion. These cases are remarkable from their resem- blance to the ordinary attack of hemiplegia. It will appear in the sequel, that they are often connected with inflamma- tion of a small defined part of the cerebral substance; that the attack may be so sudden as precisely to resemble the paralytic attack from other causes; and that the disease in the brain may not have advanced beyond the state of sim- ple inflammation, while the symptoms have gone through the usual course, and have terminated in fatal coma. In general, however, the disease in such cases will be found to have advanced to suppuration, or to the ramollissement or peculiar softening of the cerebral substance, to be after- wards more particularly referred to; while, on the other hand, in some very interesting cases of this class, the in- flammation will be found to have been entirely seated in the membranes. III. The third form of the disease most commonly af- fects children, but may also appear in adults. It is usually preceded for a day or two by languor and peevishness; these are followed by an accession of fever, which is sometimes ushered in by severe shivering. The patient is oppressed and unwilling to be disturbed, and complains of acute pain in some part of the head, with flushing of the face and im- patience of light. In many cases there is frequent vomit- ing, which continues for the first day or two; in others^ the SYMPTOMS. 29 vomiting is absent. The pain is felt in various parts of the head; frequently it extends along the neck; and sometimes pain is complained of in the arms and in other parts of the body. The pupil is usually contracted; the eye is morbid- ly sensible, and sometimes suffused; the tongue is generally white, but moist, sometimes quite clean. The sleep is dis- turbed by starting and frightful dreams, and frequently du- ring sleep there is violent grinding of the teeth. The bow- els are generally obstinate, but frequently they are natural; and I have seen the disease attended through its whole course by a spontaneous diarrhoea. After some days, slight delirium begins to appear, at first transient, perhaps only observed during the night, or on first awaking out of sleep; or in some cases the patient lies in a dozing state, and talk- ing incoherently, but out of which he can be roused so as to talk sensibly. In other cases, instead of delirium, there occurs a peculiar forgetfulness, the patient using one word instead of another, misnaming persons and things, mista- king the day, or the time of the day, or showing in some similar manner a confusion of thought, which has no resem- blance to. the delirium of fever. Sometimes he is sensible of it, and appears anxious to correct the mistakes which he has made. These symptoms ave followed by a tendency to' sleep, and this soon passes into coma. While these symptoms are going on, the pulse, which was at first fre- quent, usually falls to the natural standard or below it; the pain becomes less violent; the eye loses its acute sensibili- ty, becoming dull and vacant, often with squinting and dou- ble vision; and these are often succeeded by dilated pupil and blindness, even before the patient falls into coma. The pulse, having continued slow for a day or two, sometimes only a few hours, begins to rise again, and rises to extreme frequency; it has been counted as high as two hundred in a minute. It is through the whole course of the disease extremely unequal in frequency, varying perhaps every mi- 30 INFLAMMATORY AFFECTIONS mite, or every time that it is counted. This remarkable inequality is not observed in other diseases, except from some temporary cause, and is, in all affections of the head, a symptom deserving much attention. The patient is now in a state of perfect coma, sometimes with paralysis of one or more of the limbs, sometimes with convulsive affections; and, after he has continued in this state for a few days, the disease is fatal. The duration of the complaint is extreme- ly various; it is in some cases drawn out to three weeks, and in others, especially in young children, it is fatal in five or six days. At some period of the disease, there is generally a remarkable remission of all the symptoms, giving sanguine but deceitful hopes of recovery. This usu- ally occursjwhen the pulse is falling in frequency, or when it is beginning to rise after the slowness, and it is generally the prelude to coma. In some cases the pulse does not be- come slow, but continues through the whole course of the disease of nearly uniform frequency.—In young children who cannot describe their feelings, this form of the disease is characterized by fever, flushing, restlessness, and scream- ing, often with vomiting; these symptoms are succeeded in a few days by stupor and squinting, the pulse coming down as the stupor appears. This falling of the pulse, while the child continues in a state of great oppression, approaching to coma, is often the first symptom which points out the alarming nature of the disease. IV. The fourth form of the disease, I have observed most commonly in young persons towards the age of puber- ty and upwards. It begins like a slight feverish disorder, and for a considerable time excites no alarm. There is slight headach, with general uneasiness of the limbs, im- paired appetite, and disturbed sleep; the tongue is foul, and the pulse slightly frequent, probably from 96 to 100. Af- ter a few days the complaint appears to be going off; but, at our next visit, we are disappointed to find the patient SYMPTOMS. 31 complaining as much as at first. More active treatment is then adopted, and there is again an appearance of amend- ment; the tongue perhaps becomes clean, there is some ap- petite, and better sleep: but there is still some complaint of headach, which varies much in degree from one day to ano- ther, never severe, but never quite gone; the pulse conti- nuing a little frequent. Amid these remissions and aggra- vations, eight or ten days may pass before the disease has assumed any decided character. It is not perhaps before the sixth or seventh day, that even an attentive observer begins to remark, that the degree of headach, though not severe, is greater and more permanent than corresponds with the general symptoms of fever; that the tongue is be- coming clean, the pulse coming down, and the appetite improving, while the headach continues, with an unwil- lingness to be disturbed, and a degree of oppression which is not accounted for by the degree of fever. In this man- ner the disease may go on for several days more, until, perhaps about the 12th or 14th day, the pulse suddenly falls to the natural standard, or below it, while the headach is increased, with an evident tendency to stupor. This in- stantly marks a head affection of the most dangerous cha- racter, and the patient now lies for several days in a state of considerable stupor, sometimes with convulsion, often with squinting and double vision. The pulse then begins to rise again, and about this time there is frequently a de- ceitful interval of apparent amendment; sometimes the squinting goes off, and the eye appears quite natural, the stupor is lessened, and the patient appears easy and intelli- gent, but soon relapses into perfect coma, and dies in three or four days. The duration of the disease is uncertain; it may be drawn out to five or six weeks, or it may be fatal in two or three.—When this form of the disease attacks infants, they are observed to be languid and oppressed, with bad appetite, and disturbed slceuj there is often a disordered 32 INFLAMMATORY AFFECTIONS. state of the bowels, and to this cause the affection is proba bly ascribed. There is no urgent symptom, and no alarm is excited until, after eight or ten days, the pulse is found at 70 or 60, the pupil dilated, the eye fixed and vacant, and the child in a state of oppression tending to stupor; these symptoms are soon followed by coma, generally with squint- ing, and in a few days by death.—This form of the disease might have been considered as a modification of the former, as the symptoms differ only in degree; but I have thought it worthy of a separate description, on account of the insi- dious characters which it exhibits in the early stages, and because it is a form of very frequent occurrence. Cases indeed occur in which there is still less appearance of an af- fection of the head, than I have supposed in this descrip- tion, and in which there is not even the slightest complaint of headach through the whole course of the disease. V. The fifth form of the disease I have usually observed in adults; and it begins with violent headach without fever. The patient is found in bed, lying oppressed and unwilling to be disturbed, or tossing about from the violence of the pain. The pulse is about the natural standard, or below it, frequently about 60; the face is in some cases flushed, in others rather pale; in some cases the eye is natural, in others there is impatience of light, with contracted pupil. The pain is usually-very acute and deep-seated, and is referred to various parts of the head; frequently-it seems to shoot from temple to temple, and sometimes it is referred to the ear. There is a look of much oppression, and in some cases vomiting. Delirium frequently appears at an early period, varying in degree from day to day, until after five or six days it passes into fatal coma, the pulse having continued from 70 to 80 through the whole course of the disease. In other cases, the pulse is at first about the natural standard, afterwards fails to GO or 50, and at last rises to 120 or 130. The vision is in some cases not affected; in others squint- SYMPTOMS. 33 ing and double vision occur, and sometimes these symp- toms, after continuing for a day or two, disappear not to return; the disease, notwithstanding, going on to a fatal termination. There is in every case more or less delirium, but often slight and transient; and frequently the patient lies in a,dozing state, and talking incoherently, but out of which he can be roused, so as to talk sensibly. This con- dition, when it is not accompanied by fever, is always cha- racteristic of a dangerous affection of the brain. There is also frequently observed that peculiar forgetfulness or con- fusion of thought formerly referred to, which is different from any thing that occurs in fever, and always indicates a dangerous cerebral disease. Sometimes there is difficulty of articulation; and frequently a hesitation in speaking, from the patient not being able to recollect the word which he intended to make use of. There is generally towards the end more or less coma, which in some cases continues three or four days, in others not above twelve hours; and some- times the disease is fatal without perfect coma, the patient being able to answer questions distinctly a very short time before death. In all the forms of this dangerous affection, there is great variety in the symptoms, and much observation is required to put us fully upon our guard against the insidious characters which many of the cases assume, and the deceitful appear- ances of amendment which often take place in all the forms of the disease. Even in those cases which have assumed the most formidable aspect, every alarming symptom may sub- side. The pulse perhaps continues frequent, but it also is coming down; at our successive visits we find it falling regu- larly, and-we are disposed to hope that a few days will bring the case to a favourable termination. During this deceitful interval, which may continue for several days, I have known a parent intimate to the medical attendant that his farther vi- 34 INFLAMMATORY AFFECTIONS. sits were unnecessary, and I have known a physician take his leave, considering his patient as convalescent. As the pulse falls, the patient is disposed to sleep; this perhaps is considered as favourable; it falls to the natural standard—he then sleeps almost constantly; and in another day this sleep terminates in coma. The pulse then begins to rise again; it rises to extreme frequency, and in a few days more the pa- tient dies. All this may go on with very little complaint of headach, and without any symptom that will lead a superfi- cial observer to suspect danger, until he finds his patient gliding into coma at the very time when he expects recovery; for the period when the pulse falls to the natural standard is the time when the coma becomes evident, and the situation of the patient probably hopeless. Whenever, therefore, at any period of a febrile disease, there have been remarkable symptoms in the head, such as violent headach, with vomiting and impatience of light, stupor, convulsive affections, or af- fections of the sight,—though these symptoms may have en- tirely subsided, and the complaint may again have assumed the characters of simple fever, we must not consider the dan- ger as over, but must be upon our guard against a period of anxiety which is still before us. An attentive observer may generally remark in such cases, something which leads him te suspect, that the appearance of amendment is deceitful. Sometimes there is a dilated state of the pupil, giving to the eye a peculiar expression, and sometimes there is a remarka- j ble tendency to sleep. Frequently something unusual may be observed in the patient's manner, such as a fretfulness or querulousness which is not natural to him,—-a quick and hur- ried manner of speaking, or, on the contrary, a remarkable slowness of speech; difficult articulation, or a peculiar confu- • sion of thought and forgetfulness on particular subjects. But -1 it cannot be too strongly impressed upon the younger part of ' the profession, that cases occur in which all these symptoms SYMPTOMS. 35 are wanting, and in which the patient appears for several days to be in the most hopeful state of recovery, while in fact his disease is advancing rapidly to a fatal termination. In this description I have been entirely practical; and I have not entered upon the inquiry, whether all the forms of disease which I have mentioned are to be considered as pri- mary and idiopathic affections of the brain, or whether some of them ought to be looked upon as secondary or symptoma- tic. It is, however, an important fact, that this disorder does very often occur as a symptomatic affection in the course of other diseases; the most common of which are,—continued fever,—scarlatina,—hooping cough—measles—pneumonia— phthisis, and diseases of the kidneys. It may be useful, there- fore, to keep in view those symptoms which, in the course of any disease, indicate a tendency to this dangerous affection of the brain. They are chiefly the following: In the Head.—Violent headach with throbbing and giddi- ness—tinnitus—sense of weight and fulness—stupor __a great propensity to sleep. In many obscure and insidious cases, a constant feeling of giddiness is the only remarkable symptom. In the Eye.—Impatience of light—unusual contraction or dilatation of the pupil—double vision—squinting- blindness—distortion of the eyes outwards—paraly- sis of the muscles of the eyelids, producing, accord- ing to the muscle that is affected, either the shut eye, or the gaping eye—transient attacks of blind- ness or double vision—objects seenthat do not ex- ist—a long-sighted person suddenly recovering or- dinary vision. In the Ear.—Transient attacks of deafness—great noise in the ears—unusual acuteness of hearing. 36 INFLAMMATORY AFFECTIONS. In the Speech.—Indistinct or difficult articulation—unusual quickness of speech, or unusual slowness. In the Pulse.—Slowness and remarkable variations in fre- quency. In the Mind.—High delirium—transient fits of incoherence —peculiar confusion of thought, and forgetfulness on particular topics. In the Muscles.—Paralytic and convulsive affections— sometimes confined to one limb, or even part of a limb; and a state of rigid contraction of particular limbs. In the Urine.—There frequently occurs a remarkable dimi- nution of the secretion—sometimes nearly amount- ing to complete suppression; and connected with this diminution there is often a frequent desire to pass urine, occasioned probably by the increased acrimony, as the quantity diminishes. In this important diagnosis, however, minute attention to the correspondence of the symptoms is of more importance than any particular symptom; thus, the peculiar oppression which accompanies a high degree of fever is familiar to eve- ry one, and is not reckoned an unfavourable symptom; the same degree of oppression occurring without fever, or with very slight fever, would indicate a head affection of the most dangerous character. In the same manner, a degree of head- ach and of delirium, which, accompanying a high degree of fever, would be considered as symptomatic, accompanying slight fever, would indicate a dangerous affection of the brain. In the preceding outline, the symptoms have been de- scribed from the cases of most frequent occurrence. We meet with numerous varieties which it is impossible to in- clude under any general description. One of the most re- markable modifications is that which comes on with a sud- den attack of palsy, so as to be considered as an apoplectic SYMPTOMS. 37 rather than an inflammatory affection: it is generally con- nected with inflammation of a portion of the cerebral sub- stance, but may also occur in connexion with inflamma- tion of the membranes. This form of the disease may also take place in a more chronic manner, in which it goes on for months. In such cases, it is generally distinguished by headach, often confined to one side of the head—loss of memory—affections of various organs, as the eye, the ear, or the tongue—convulsive affections—palsy of one limb, or one side of the body, and at last ends by coma and death. In such cases ramollissement of a part of the brain is ge- nerally met with, but sometimes the part is found of a dark red colour, and rather firmer than the surrounding parts. In the particular symptoms likewise, numerous varieties occur, as, for example, in the state of the pupil: in some cases it continues sensible to the last, and in others it is un- usually contracted; sometimes after being dilated and in- sensible, it again becomes sensible: occasionally one pupil is found to contract, while the other is dilated and insensible. Alternate contraction and dilatation may also be observed; and a singular condition of the pupil is sometimes met with in which it becomes ,dilated on the approach of a bright light. I have observed this several times, and am quite satisfied of the fact, but am unable to point out the particu- lar nature of the cases in which it occurs. It will be found exemplified in one of the cases to be afterwards described. Remarkable recoveries of the senses also occur, often a short time before death. Some time ago I saw a boy aged seven, who had perfect blindness and loss of hearing, followed by coma; three days after the occurrence of these symptoms he recovered his sight and hearing for a few hours, knew those about him, and talked sensibly; then relapsed into coma and died next day. The usual appearances were found on dissection, the effusion being in large quantity. I have also seen squinting continue for a day or two, and 6 38 INFLAMMATORY AFFECTIONS. then disappear, the disease running its course to a fatal ter- mination without any recurrence of it. In the preceding observations I have said little in re- gard to the state of the bowels, because I am satisfied that there is no condition of them which is peculiar or essential to this class of diseases. They are generally obstinate, but sometimes easily regulated, and sometimes spontaneously loose through the whole course of the disease. The mo- tions also vary exceedingly in character, exhibiting in dif- ferent cases, and at different periods of the same case, all the various forms of morbid appearance, which are met with in other febrile diseases. One of the most common is the evacuation of much green matter like tea leaves, or chop- ped spinage, and this, I believe, is the appearance which has been considered so peculiar to affections of the brain, as to have received the name of hydrocephalic stools. This doc- trine, I am satisfied, is entirely unfounded in point of fact, and therefore, when it is proposed as a rule of diagnosis, I must consider it as highly dangerous. Every practitioner who divests himself of system, and attends to what is pass- ing before him, will find, that the character of stools here referred to, is by no means peculiar to affections of the brain; and, that hydrocephalus runs its course with every possible variety in the appearance of the evacuations, and that even at the most advanced periods of the disease, they may often be found perfectly natural. While it is therefore proper that, in the investigation of this disease, every attention , shall be paid to the character of the evacuations, and every means used to correct them when they are morbid, I must consider it as erroneous in principle^ and in practice dan- gerous, to suppose that any particular character of stools is characteristic of hydrocephalus. TERMINATIONS 39 SECTION II. OF THE PRINCIPAL SEATS AND TERMINATIONS OF THE DISEASE. The preceding outline will serve as a general view of the symptoms, which indicate inflammatory action of some of the parts within the head. When we come to investi- gate this class of diseases in a pathological point of view, they resolve themselves into important varieties, arising probably from the particular part which is the primary seat of the disease; and important modifications depending upon the manner in which the inflammation terminates. The varieties in the seat of the inflammation may be re- ferred to the following heads: I. The Dura Mater. II. The Pia Mater and the Arachnoid. These may be taken together, both because it is extremely difficult to dis- tinguish inflammation of the Pia Mater from inflammation of the Arachnoid, and because, in point of fact, they seem in general to be affected at the same time. III. The Substance of the Hemispheres. IV. The dense white matter forming the central parts of the brain,—the septum lucidum, the fornix, and the corpus callosum. To investigate the phenomena connected with these va- rious seats of disease, will be one of the objects of the fol- lowing dissertations; and at the same time it will be of con- sequence to keep in view the peculiarities arising from the modes in which the inflammation terminates. These are chiefly the following. The disease may be fatal. I. In the Inflammatory Stage, and this may occur, 40 INFLAMMATORY AFFECTIONS. whether it be seated in the substance of the brain, or in the membranes, especially the Pia Mater. In the most distinct- ly marked cases, however, of this termination, the inflam- mation is found in the substance of the hemispheres. II. By Serous Effusion. In the earlier investigations of this class of diseases, too much importance was perhaps attached to the effusion, as if it alone constituted the dis- ease called acute hydrocephalus. The symptoms were as- cribed to the compressing influence of the effused fluid, and the practice was directed chiefly or entirely to promoting its absorption. It is now, I imagine, very generally ad- mitted, that the effusion in acute hydrocephalus is to be con- sidered as one of the terminations of inflammatory action, though there are certainly other causes, from which serous effusion in those parts may arise. Increased effusion from a serous membrane, appears to take place under two very different conditions of the>part. (1.) Inflammation of the membrane itself, or of the parts immediately adjacent to it. In this manner we see effusion take place in the cavities of the Pleura, and the Peritonaeum from inflammation of these membranes. The effusion in such cases varies considerably in its characters, being in some cases limpid, in others opaque and milky, and in others mixed with yellow flocculent matter, or sometimes being nearly purulent. It is difficult to say on what these varie- ties depend. We may perhaps be allowed to ascribe them in some degree to the seat of the inflammation, and to sup- pose that when the membrane itself is inflamed, the fluid will be flocculent; and that it will be limped, when the in- flammation is seated in the parts which the membrane co- vers, the serous vessels of the membrane being thus affect- ed only in a secondary manner. We observe the same va- rieties in the appearance of the effused fluid in the brain, which we find in the other serous cavities; and upon the whole view of the pathology of the disease, we may consi- } TERMINATIONS. 41 der the principle as fully established, that inflammatory ac- tion is the source of the effusion in all those acute affections of the brain, which have generally been included under the term acute hydrocephalus. (2.) There is, however, another source of serous effusion entirely distinct from this, viz. interruption of the circula- tion in the veins in any part of the body. In this manner, we see a tightly bandaged limb become cedematous below the seat of the pressure, and we find anasarca of the whole or part of a limb produced by the pressure of tumours, and ascites arising from induration of the liver. Whenever such interruption occurs in the circulation of a vein, it ap- pears that increased effusion takes place from the exhalant branches of those arteries with which the vein is more im- mediately connected, depending probably upon a state of congestion in these parts, which in its effects is nearly ana- logous to inflammation. Such a. state of impeded circula- tion evidently takes place in the brain from a variety of causes; such as the pressure of tumours, chronic disease of the sinuses, tumours on the neck, certain diseases of the lungs and of the heart, and probably from that very re- markable condition'of the brain to which I have proposed to give the name of simple apoplexy. From serous effu- sion produced by such causes as these, probably arise those affections which have been called Chronic Hydrocepha- lus and Serous Apoplexy. In regard to its seat, the effusion of course varies in dif- ferent cases. It is found in the ventricles,—under the arach- noid,—betwixt the arachnoid and dura mater;-and there is every reason to believe that it also takes place betwixt the dura mater and the bone, though the fluid effused in this situation escapes when the head is open. It is occasionally met with in a cavity formed by the separation of the lami- nae of the septum lucidum. Cases have been described in which the effusion was confined to one of the lateral ven- 42 INFLAMMATORY AFFECTIONS. tricles. This I have not seen, and it is probable that it could only take place in consequence of the obliteration of the communicating opening. In quantity, the fluid varies from a few drams to eight or ten ounces, or more. As to quality, it is sometimes limpid, sometimes bloody, and sometimes turbid, containing shreds of flaky matter. In some cases it is seen in the ventricles exhibiting all the sen- sible qualities of pus. Generally, however, it seems to contain but a very small proportion of animal matter. In the experiments of Dr. Marcet, a thousand grains yielded less than two grains of animal matter, which consisted of muco-extractive with a trace of albumen. In other cases, however, it is coagulable, and the truth seems to *be, that it varies exceedingly, both in the quantity and in the qua- lity of the animal matter which is contained in it. III. By deposition of False Membrane.—This arises from inflammation of the membranous parts, and it may be found betwixt the bone and the dura mater, or betwixt the dura mater and the arachnoid. But the most common seat of it is under the arachnoid; where it is often found of great extent, communicating a yellow colour to a great part of the hemisphere. In some cases it is found following the course of the arachnoid alone, or dipping slightly betwixt the con- volutions by small triangular projections; in other cases, it follows entirely the course of the pia mater, producing com- plete adhesion of the convolutions to each other. It is oc- casionally found within the ventricles, covering the surface of the choroid plexus; and a very common seat of it is the upper surface of the tentorium. IV. By Suppuration.—A thin uniform layer of puri- form matter is often found under the arachnoid, and occa- sionally betwixt the arachnoid and the dura mater, and be- twixt the dura mater and the bone. It is also met with in distinct small cavities formed by partial adhesions of the membranes to the bone or to each other, and it is occasion- TERMINATIONS. 43 ally found in the ventricles. But the principal seat of pu- rulent matter is in the substance of the brain; and here either it is met with in distinct defined abscesses, lined by soft cysts, or an extensive portion of the cerebral substance is found in a broken down corrupted state, in which, with- out any well-defined cavity, pus is found mixed with the disorganized cerebral matter. The cerebellum is a frequent seat of abscesses, and they may be found of small size but well defined in the centre of any of the more minute parts, as the medulla oblongata, or the pineal and pituitary glands. An example will be given of a well-defined abscess, no larger than a small bean in the substance of the corpus striatum. V. By Ramollissement.—A peculiar disorganization or softening of the brain, which has now received that name, —a term adopted from the French to express the peculiar morbid appearance. It consists in a part of the cerebral substance being broken down into a soft pulpy mass, retain- ing its natural colour, but having lost its cohesion and con- sistence. It differs entirely from suppuration, having nei- ther the colour nor the fetor of pus; but the white parts of the brain in which it is most commonly observed retain their pure milky whiteness. It may be found in any part of the brain; but the most common seat of it in my obser- vations is the dense white matter forming the corpus callo- sum, fornix and septum lucidum. The septum is generally found in such cases perforated by a ragged irregular opening, and the fornix has either entirely lost both its figure and its-consistence, or retains its figure while it is left untouched, but falls down into a soft pulpy mass, when the slighest at- tempt is made to raise it. When I formerly endeavoured to contribute something to the pathology of this remarkable affection, I had no hesi- tation in considering it as one of the results of inflammation of the cerebral substance. Since that time, it has been in- 44 INFLAMMATORY AFFECTIONS. vestigated with much attention, by M. Rostan and other French pathologists) and a different view of the nature of the affection has been strongly contended for by these emi- nent individuals. They consider it as an affection of the brain entirely sui generis, and M. Rostan, in particular, seems to look upon it as a peculiar and primary disease of the brain, though he admits it is sometimes the result of in- flammation. From all ihe facts which are now before us, in regard to this interesting affection, I think we are enabled to arrive at the conclusion, that it occurs under two modifications which differ essentially from each other. In the cases of M. Rostan, the disorganization was observed chiefly in the external parts of the brain; it occurred almost entirely in very old people, few of his cases being under sixty years of age, many of them seventy, seyenty-five, and eighty. It was found in connexion with attacks of a paralytic or apo- plectic kind, many of them protracted; and was often found combined with extravasation of blood, or surrounding old apoplectic cysts. On the contrary, the affection which I had been anxious to investigate, was found chiefly in the dense central parts of the brain, the fornix, septum lucidum, and corpus callosum, or in the cerebral matter immediately sur- rounding the ventricles; and occurred in persons of various ages, but chiefly in young people and in children. It took place in connexion with attacks of an acute character, chiefly the character of acute hydrocephalus; and it was in many cases distinctly combined with appearances of an inflamma- tory kind, such as deep redness of the cerebral matter sur- rounding it, suppuration bordering upon it, and deposition. of false membrane in the membranous parts most nearly connected with it. We may even observe in different parts of the same diseased mass, one part in the state of ra- mollissement, another forming an abscess, while a third retains the characters of active inflammation, and probably TERMINATIONS. 45 exhibits, as we trace it from one extremity to the other, the inflamed statepassing gradually into the state of softening. Remarkable examples of this will be given in the sequel, and another of a different nature, in which an opening in the septum lucidum produced by the ramollissement, was entirely surrounded by a ring of inflammation. This is the affection which I have endeavoured to investigate, and which I consider as one of primary importance in the pathology of acute affections of the brain, and upon the grounds now shortly referred to, I cannot hesitate to consider it as a re- sult of inflammation. When we compare the facts now alluded to, with the ob- servations of M. Rostan and his friends, I think we may ar- rive at a principle by which the apparent difference may be reconciled. The principle to which I refer is, that this pecu- liar softening of the cerebral matter is analogous to gangrene in other parts of the body; and that like gangrene it may arise from two very different causes, inflammation, and fail- ure of the circulation from disease of the arteries. The for- mer I conceive to be the origin of the affection which I have described, and the latter to be the source of the appearances described by M. Rostan. If this doctrine be admitted, the difficulty is removed; and I do not see any good objection to it. Gangrene from inflammation is familiar to every one; and equally familiar, though very different in its origin and concomitant symptoms, is gangrene from disease of the arteries of any particular part of the body. Ossification of the arteries of the brain to a very great extent is a common appearance in elderly people, and seems to be a very fre- quent source of apoplexy with extravasation of blood, at advanced periods of life. It appears extremely probable that it may be the source of that particular condition of a part of the brain which terminates in the ramollissement of M. Rostan, and indeed he distinctly points at this explana- tion of it. On the other hand, I am still disposed to con- 7 46 INFLAMMATORY AFFECTIONS. tend, that the ramollissement of young persons occurring in acute affections, and seated chiefly in the central parts, is one of the terminations of inflammation in that particular structure. I conceive it to be an affection of primary im- portance in the pathology of acute affections of the brain, and to mark a peculiar seat of the inflammation of very fre- quent occurrence. It is often combined with suppuration in other parts of the brain, and very often with effusion in the ventricles; but the peculiar interest of it is observed in those cases, in which it is the only morbid appearance, and in which it is sometimes of small extent. Of this some remarkable examples will be given in the sequel, in which the perforation of the septum lucidum, by softening of a part of its substance, and similar softening of the fornix, were the only morbid appearances in cases which were fa- tal with all the usual symptoms of acute hydrocephalus. VI.—As terminations of the disease in a chronic form, we still have to remark thickening of the membranes, con- traction and obliteration of the sinuses, caries of the bones, and some other affections of the external parts, which will be more particularly referred to in the sequel. In the pathology of acute hydrocephalus, we may con- sider it as probable, or almost ascertained, that the serous effusion is only one of the terminations of that inflammatory condition of the brain, which is a great and leading object of attention in the pathology and the treatment. Some of the other terminations are scarcely less frequent; particu- larly the ramollissement of the central parts, which is some- times met with as the only morbid appearance, and is found combined with the effusion in a very large proportion of the ordinary cases of hydrocephalus. Other cases, in which the symptoms closely resemble those of hydrocephalus, will be found to terminate by the undefined suppuration, or by this combined with serous effusion, or with the ramollissement TERMINATIONS. 47 of the central parts. In fact, we do not often meet with any one of the terminations uncombined, and it is impossible to anticipate from the symptoms, in what manner the disease may terminate in any particular case. Serous effusion, un- combined with any other morbid appearance, I have usually observed in that which I have described, as the fourth form of the disease, in which the symptoms are slow and insi- dious in their progress, and at no period exhibit much ac- tivity. In the cases of this kind in which the pain is more severe, and the symptoms are more violent, I have generally found either effusion combined with the ramollissement of the central parts, or undefined suppuration. In that which I have described as the second form of the disease, I have generally observed the encysted abscess or the deposition of false membrane between the araehnoid and pia mater. But these results are by no means uniform; and the ramollisse- ment in particular may occur with very slight and insidious symptoms. The various terminations, indeed, are very often combined together, and all of them are generally com- bined with more or less of serous effusion. On what these varieties depend, is at present in a great measure matter of conjecture. There is some reason to believe, that the darker or cortical parts of the brain are the chief seats of suppura- tion, and that the inflammation of the more central white matter terminates chiefly by ramollissement. The disease is also greatly modified by the activity of the inflammation, depending probably upon the constitution of the patient. Thus, in some cases, we find it assuming the highest charac- ters of active inflammation, in others, consisting of the pure scrofulous inflammation with the lowest degree of activity, and in others, forming numerous modifications by which these two extreme forms pass one into another by almost insensible gradations. Without attempting any general con- clusions on these points, I shall proceed to describe a se- lection of cases calculated to illustrate the various modifi- 48 INFLAMMATORY AFFECTIONS. cations of inflammation of the membranes and of the sub- stance of the brain. SECTION III. INFLAMMATION OF THE DURA MATER. Idiopathic inflammation of the dura mater is a very un- common affection; the folio wing is the only distinctly marked case of it that has occurred to me. Case I.—A lady aged 22, in the evening of 15th March 1820, was suddenly seized with severe pain in the left temple; I saw her for the first time on the following morn- ing, when I found the pulse about 100, the tongue white and moist; some pain continued in the left temple, but it was not severe; and her whole appearance corresponded with that of mild continued fever, though with some characters of an affection of the brain. After general and topical bleeding, with purgatives, &c. she was very much relieved; she occasionally complained of pain in the head, but at other times was entirely free from it, and mentioned only a feel- ing of confusion. The pain, when present, was occasionally referred to the left temple, and at other times was more general, extending over the upper part of the head. Amid these changes, the first week of the disease passed, with much of the character of continued fever; the tongue white, the pulse varying from 96 to 110, the nights sometimes quiet, and sometimes restless. In the beginning of the se- cond week, a swelling appeared in the left upper eyelid; her look was now more oppressed, the pulse varying from 96 to 120; the pain varying as before, sometimes a good deal complained of and sometimes quite gone; and one day she complained of acute pain in the right ear. On the 27th INFLAMMATION OF THE DURA MATER. 49 she began to have severe shiverings, followed by heat and perspiration, for which an eminent physician ordered her the bark in large doses. For two days after this she seemed much better, the pulse from 90 to 96, and every symptom greatly relieved. The swelling on the left eyelid was punctured, and discharged a good deal of purulent matter; and a probe introduced by the opening passed to a great depth along the upper part of the orbit, where the bone in some places felt bare. On the evening of the 29th, she was seized with slight convulsion, but it soon subsided, and af- ter it she seemed quite as well as on the two preceding days, all the previous symptoms being very much relieved. On the 30th, there was more complaint of headach, with an oppressed look, and the pulse varied exceedingly, being sometimes very rapid, and at other times little above the natural standard. On the 31st, there was no particular change; she was quite intelligent, and all her senses were entire. When she was last visited, about nine o'clock at night, she complained of some uneasiness across the crown of the head; but no other change was remarked in the symptoms. Be- tween one and two in the morning, she was observed to be slightly incoherent, and soon after sunk into a state of low- ness; did not speak, but seemed quite sensible, and died at three. Very slight delirium had been observed on a prece- ding night, about the 28th, and once she had complained of dimness of sight, but none of these symptoms had been again taken notice of. Inspection.—On raising the, skull-cap a good deal of pu- rulent matter escaped, which had been collected betwixt the bone and the dura mater. The space in which it had been contained was defined by an irregular elevated margin of adventitious membrane, by which the dura mater had ad- hered to the bone, the included space being about the size of a crown piece : it was on the anterior part of the right he- misphere. The dura mater included within this space was 50 INFLAMMATION OF THE DURA MATER. depressed ; its surface was in some places ulcerated, and in others black, but the membrane was quite entire, and the bone was sound. On raising the dura mater, the inner surface of this portion had the same irregular ulcerated appearance as the outer surface, and when held up to the light, the mem- brane at the part appeared to be in some places considerably thickened, in others very thin. The right hemisphere of the brain, over all that part of it which is usually exposed in the ordinary way of opening the head, was covered by a thin uni- form layer of very thick purulent matter, spread over it with great equality, and this being removed, an extensive stratum of adventitious membrane was found under the arachnoid. It was irregular in thickness, being most remarkable on the an- terior part of the hemisphere, and disappearing on the pos- terior part It followed the course of the arachnoid, cover- ing the openings of the convolutions, but not dipping between them. The pia mater betwixt the convolutions was highly vascular, but without any deposition. On cutting into the sub- stance of the right hemisphere, the cerebral matter was to a slight depth of a dark livid colour, but without any change of structure. There was no effusion in the ventricles, and the brain in all other respects was quite healthy. The suppura- tion in the left orbit was confined to a cavity betwixt the or- bit and the ball of the eye, without any disease of the bones, and without any internal disease on that side of the cranium. In this remarkable case, the inflammation of the dura ma- ter appears to have been the primary disease, though it was afterwards complicated with extensive inflammation of the arachnoid. The only case which I have met with in any de- gree analogous to it, is one which is mentioned by M. Fizean, though it differs from it in being complicated with disease of the bone.* A boy aged 15, had a "fluxion" of the right cheek and pain of the teeth. After some days it ceased, and * Journal de Med. torn. xi. new scries, p. 523. IDIOPATHIC. 51 removed to the left side of the head, where it occupied entire- ly the eye and its dependencies. He then had irregular at- tacks of fever, with want of sleep and loss of appetite, and about the 7th day considerable delirium, frequently attempt- ing to get out of bed. On the Sth day, the left eyelid was swelled so as to close the eye, and on raising it the eyeball ap- peared unusually prominent. He had nausea and severe headach, but was quite sensible, and the fever was moderate: some delirium occurred towards night, and the swelling ex- tended beyond the eyelids over the forehead. On the 9th day there was permanent delirium; on the 10th, coma and death. The left eyelid and the integuments of the left side of the forehead were imbued with purulent matter; the frontal bone was denuded and carious for a considerable space; the abscess penetrated the orbit, and pus was found in the upper and back part of it, where the bone also was denuded. The caries of the frontal bone occupied the whole thickness of it, and extended in length somewhat beyond the roots of the hairs, and transverse- ly from the external orbitar process beyond the nose. The dura mater was detached and covered with pus over a space corresponding with the external disease, but it was not de- tached from the superior part of the vault of the orbit. The arachnoid was covered with purulent matter; there was very little fluid in the ventricles, and the hrain in other respects was healthy. These are the only cases that I am acquainted with of idio- pathic inflammation of the dura mater taking place in this manner: but the disease is frequently met with in another form. It occurs in connexion with affections of the ear and of the petrous portion of the temporal bone. This insidious and highly dangerous affection generally be- gins with pain in the ear, and for some time may be consider- ed merely as a common ear-ach. Sometimes discharge of matter takes place from the ear, which is expected to relieve the pain; but the pain continues or becomes more violent. The patient becomes oppressed and drowsy, then slightly delirious, 52 INFLAMMATION OF THE DURA MATER. often with shivering, and at last comatose. In other cases, there is no discharge of matter, but the patient, after complaining for a day or two of deep-seated pain in the ear, becomes restless and forgetful,—lies rolling his head from side to side, or tossing about his arms, and in a short time sinks into coma. In other cases, again, the affection supervenes upon the sudden cessa- tion of a purulent discharge from the ear, which perhaps had been of some standing ; such as that which often follows scar- latina. The sudden disappearance of the discharge in these cases, is followed by pain in the ear, this by languor and drow- siness, and in a few days by coma. The pulse is in some cases frequent, in others natural, and in others below the natu- ral standard. The nature of this disease is illustrated by dis- section. There is generally caries of the pars petrosa of the temporal bone, sometimes confined to a small spot of it. A portion of the dura mater corresponding to this part is in- flamed and thickened, spongy, or ulcerated, and generally de- tached from the bone. Betwixt it and the arachnoid, there is commonly a deposition either of purulent matter, or of false membrane, and this deposition sometimes extends along the tentorium. In some cases there is a superficial abscess of the brain itself, or of the cerebellum, often with effusion in the ventricles, and the other usual marks of general disease in the brain. Matter is also frequently found in the cells of the pe- trous portion, in the canals of the ear, and in the cavity of the tympanum, and sometimes it extends into the cells of the mas- toid process. This disease will be illustrated by the three following cases, the third of which is valuable from showing the disease in an intermediate stage of its progress, the fatal event having taken place from another affection. Case II.—A gentleman aged 20, on the 20th of January, 1820, complained of violent toothach, seated in a tooth on the right side of the upper jaw. On the 21st, the pain extended IDIOPATHIC. 53 into the ear, without any other symptom. On the 22d, the pain continued in the ear, and extended towards the tem- ple. He lay in bed part of the day, but got up afterwards. Leeches were applied, and he took some laxative medi- cine, which he vomited, and he had afterwards repeated vo- miting. On the 23d, the pain was more general over the head and across the forehead, with some vomiting, and at night he had shivering. In the night he became incoherent' and delirious; he was then seen by a surgeon, who found him considerably incoherent, but complaining of severe head- ach ; the pulse 70 and-of moderate strength. I saw him on the 24th; his pulse was then 60, his face rather pale; the head- ach continued, and was chiefly referred to the forehead; his look was vacant; he answered questions distinctly when he was roused, but talked incoherently when his attention was not kept up. He was now treated by repeated general bleed- ing, which he bore well; cold applications, blistering, purga- tives, &c. On the evening of the 24th, there was considera- ble shivering. On the 25th, there was less complaint of pain, but more incoherence, and a tendency to stupor, pulse from 60 to 70.—26th, Pulse from 100 to 120.—27th and 28th, Lit- tle change; answered questions when roused, but when not spoken to, lay either in an oppressed state, or talking inco- herently; pulse varying from 96 to 120. On the 28th, there was some discharge of fetid matter from the right ear. 29th, Constant incoherent talking, pulse 96, of good strength; the right eye was suffused, the ball of it appeared turgid and en- larged, and the cornea was covered with a yellowish slough. In the course of this day, the mouth was at times observed to be drawn to the left side, especially when he was drinking. At night he began to sink, and died at five in the morning of the 30th. Inspection.— There was some effusion under the arach- noid on both "hemispheres; much effusion in the ventricles, and extensive ramollissement of the septum lucidum, the 8 54 INFLAMMATION OF THE DURA MATER, fornix, and the cerebral matter bordering upon both lateral ventricles. There was extensive caries of the right tem- poral bone; behind the ear on the thin part of the bone it was very dark-coloured; and the petrous portion was dark- coloured, very soft, and when cut into, discharged matter from its cancelli and from the cavity of the ear; the dura mater corresponding to the temporal bone was much thick- ened. The part of it which lay anterior to the petrous por- tion was in a state of recent inflammation; the part behind the petrous portion was mueh thickened and spongy; and between it and the bone there was a deposition of thick pu- rulent matter. From this place the disease had spread along the tentorium, and over nearly the whole surface of the cerebellum, on almost every part of which there was a deposition of coagulable lymph, with thick flocculi of puru- lent matter; this was most abundant on the tentorium, and on the right and posterior parts of the cerebellum, and it was traced into the fourth ventricle. Under the cerebel- lum there was a considerable quantity of pus, and in its substance there was- a small abscess in the posterior part betwixt the lobes. Case III.—A girl aged 9, had been liable to attacks of suppuration of the ear, which were usually preceded by se- vere pain and some fever. She suffered one of these attacks in the left ear in July 1810, from which she was not re- lieved, as formerly, when the discharge of matter took place, but continued to be affected with pain, which extend- ed over the forehead. In consequence of this, I saw her, for the first time, on the day on which the discharge took place, and found her affected with pain across the forehead, impatience of light, and some vomiting; her look was op- pressed, and the pulse 84. Blood-letting, purging, blister- ing, and mercury, were employed without relief. On the second day, the pulse was 60; on the 3d, there was slight CONNECTED WITH DISEASE OF THE EAR. 55 and transient delirium, a degree of stupor, and slight con- vulsions. She complained once or twice of pain in the back of the head, but her chief complaint was always of the fore- head. She lay constantly with both her hands pressed upon her forehead, and moaning from pain, of which there had not been the least alleviation; 4th day, pulse from 80 to 86; no change in the symptoms; oppression, but no coma: 5th day continued sensible, and died suddenly in the afternoon, without either squinting, blindness, or coma, and the pulse having continued under 90. The left ear had continued to discharge matter, and an opening had formed behind the external ear, from which also there was a purulent discharge. Inspection.—A- considerable quantity of colourless fluid was found in the ventricles of the brain. The brain in other respects was healthy. In the left lobe of the cerebel- lum there was an abscess of considerable extent, containing purulent matter of intolerable fetor. The dura mater, where it covered this part of the cerebellum, was thickened and spongy, and the bone corresponding to this portion was soft and slightly carious on its inner surface; but there was no communication with the cavity of the ear. The opening behind the ear merely passed behind the external ear, and communicated with the external meatus. Case IV.—A young lady aged 15, had been liable, for six or seven years, to attacks of pain in the right ear, fol- lowed by discharge of matter, but she had been free from any of these attacks for some time previous to the illness which forms the subject of the following history. On the 25th of April 1822, she complained of cold shivering through the day, and in the evening had headach with pain in the right ear, and these symptoms continued on the following day On the 28th, she was seen by Mr. Brown, who found her with quick pulse and foul tongue, severe pain in the ear, and slight headach. On the 29th, some discharge took 56 INFLAMMATION OF THE DURA MATER, place from the ear, but without relief of the pain, which continued with violence on the following day. On the 1st of May, the pain was somewhat abated in the ear, but had extended over the right side of the head; pulse frequent; general and topical blood-letting were employed with par- tial relief. I saw her on the 3d: the headach was then ra- ther abated; the pulse was frequent and weak; she had a pale unhealthy aspect, and a look of oppression, bordering upon coma. The pain was chiefly referred to the parts above and behind the right ear, where the integuments were painful on pressure, and at one spot near the mastoid process, felt soft and elevated; a puncture was made at this place with a lancet, but nothing was discharged. To- pical bleeding, blistering, &c. were recommended. (4th) Pulse in the morning 148, in the course of the day it fell to 84,—look of much languor and exhaustion. (5th) Dark- coloured matter of intolerable fetor began to be discharged from the puncture which had been made behind the ear. The opening here was enlarged, and a probe being intro- duced, the bone was felt bare and rough over a considera- ble space; headach much relieved, pulse natural. (6th) Great discharge from the opening, headach much relieved, pulse 112; complained of some pain in the left side of the thorax, and there was considerable diarrhoea. (7th) No headach; there was much discharge of fetid matter from the opening near the mastoid process, and a probe intro- duced by it, passed backwards and downwards under the integuments of the neck as far as the spine. (8 th) Pain in the thorax continued, and was now so urgent that a small bleeding was employed with partial relief; it could not be carried farther on account of her increasing weakness— pulse 140. (9th) Said she felt better, and made no com- plaint of pain—pulse very rapid, and strength sinking— died on the 10th. Inspection.—Every part of the brain was in the most CONNECTED WITH DISEASE OF THE EAR. 57 healthy state, except a small portion on the right side near the ear, which was of a dark leaden colour; the tinge, how- ever, was found to be entirely superficial. The right tem- poral bone, externally, was bare through a great part of its extent; internally, it was in many places rough and dark- coloured, and there was some dark-coloured matter betwixt it and the dura mater. The dura mater at this place was for a considerable space thickened, spongy, and irregular; the coats of the right lateral sinus were considerably thick- ened through its whole extent, and the capacity of the sinus was very much diminished, by a deposition similar to that which occurs in the cavity of an aneurism. The internal ear contained dark-coloured matter. The left cavity of the pleura contained fully a pound of puriform fluid; the left lung was collapsed, dense, dark-coloured, and covered by a coating of coagulable lymph. These examples will be sufficient to illustrate this insidi- ous and dangerous affection; several analagous cases are men- tioned by Itard, but they do not present any important va- rieties in the phenomena. One of them was complicated with extensive swelling of the parotid, and the side of the face; there was deep-seated lancinating pain in both ears, and the case was fatal by coma in eight days. There was much purulent matter in the internal ear and in the Eusta- chian tube, with inflammation and thickening of the dura mater, and copious deposition betwixt it and the bone.* The termination of this affection by coma is sometimes sud- den and unexpected: I lately saw a gentleman, about se- venty years of age, who had been keeping the house for a few days, on account of a dull uneasiness in one ear; it was referred to a space, which he defined by planting the points of his fingers round the ear, so as to include a space of about three inches in diameter. There was no constitutional dis- * Itard, Traite* des Maladies de FOreille. 58 INFLAMMATION OF THE DURA MATER, turbance, and no danger was apprehended, until one morn- ing he was found in a state of perfect coma, and died in the afternoon. He was moribund when I saw him, and no ex- amination of the body was obtained, the case being at a dis- tance in the country. The affection may be also suddenly fatal without coma. A young man mentioned by Dr. Powel,* who had been liable to suppuration of the ear and deafness, was seized with deep-seated pain in the right ear without fever. Relief was obtained from opiates, but the pain continued, with a fetid discharge. On the 10th day of the disease, after a violent paroxysm of pain, he sunk ra- pidly and died. The pars petrosa was found black and ca- rious; the dura mater corresponding to it was black, sloughy, and separated from the bone; and under the dura mater there was a collection of pus and coagulable lymph amounting to several ounces, which covered the whole superior surface of the right hemisphere. Mr. Parkinsont mentions a boy, aged fourteen, who had been affected for two months with headach, and discharge of matter from the right ear; a week before his death the pain increased, and was accompanied by great debility, giddiness, and some vomiting. He continued in this state without stupor, or any other remarkable symptom, until the day of his death, when he was suddenly seized with convulsions, and died. An abscess was found in the middle lobe of the right hemisphere of the brain, and ano- ther in the cerebellum. There was extensive caries of the pars petrosa, with effusion in the ventricles to the extent of three ounces. This affection occurs most frequently in persons who have shown a tendency to disease of the parts, by purulent dis- charges from the ear, or deep-seated suppuration behind the ear. A very unmanageable abscess is often met with in this situation, from which a probe can be passed to a great * Transactions of the College of Physicians, vol, v. f London Medical Repository, March 1817. CONNECTED WITH DISEASE IN THE NOSE. 59 depth into the cells of the mastoid process. It is generally a scrofulous affection, extremely tedious in its progress, and sometimes terminates fatally, by inflammation spreading to the dura mater. The matter which is formed in these affections, whether it be in the substance of the brain or betwixt the membranes, sometimes finds a vent by the ear, the dura mater being ul- cerated, and the bone perforated by the caries; and in this way alarming symptoms are sometimes unexpectedly re- lieved. The relief indeed is in general but temporary: the patient continues liable to pain, followed by discharges from the ear, and at last dies comatose, often with gradual aboli- tion of the faculties, tremors or general convulsions. In some cases of this kind, there is reason to believe that a communication had existed for a length of time betwixt the ear and a diseased cavity within the cranium, and that the discharge thus afforded to the matter from time to time had retarded the fatal event. In a boy, mentioned by Mr. Bro- die, there was in the left hemisphere of the brain a cyst about three inches in diameter, containing thick dark-co- loured pus; the lower part of it rested upon the petrous por- tion of the temporal bone, and there was an opening through the cyst, dura mater, and bone, forming a free communi- cation betwixt the cavity of the abscess and the meatus; au- ditorius externus.* Examples, indeed, have occurred which would lead us to suppose, that in some such cases the relief is permanent. A young lady in Edinburgh, several years ago, after the usual symptoms in the head,hadlain for three or four days in a state of perfectcoma, andher situation was considered as entirely hopeless. Her medical attendants paying their visit as a matter of form, were astonished to * Transactions of a Society for the Improvement of Medical and Surgi- cal Knowledge, vol. iii. 60 INFLAMMATION OF THE DURA MATER, find her one day sitting up and free from complaint; a co- pious discharge of matter had taken place from the ear with immediate relief, and she continued in good health. It is, however, by no means certain, that in such a case as this the discharge came from the cavity of the cranium; for there is reason to believe, that extensive suppuration within the cavity of the tympanum is capable 'of producing symptoms of great urgency, especially if there should be any difficulty of finding an outlet. In a case of this kind by Itard, the matter, after urgent symptoms, escaped by the Eustachian tube, and, by constantly dropping down in that direction, produced cough and great irritation of the larynx; after partial relief in this manner, the symptoms in the head and in the ear returned, and were at length re- lieved by the puncture of the membrana tympani. A disease, analogous to that now described, sometimes occurs in the nose. A person who has been liable to pain in the forehead, and purulent discharge from the nose, be- comes at last forgetful and delirious, and dies comatose. The ethmoid bone is found carious, the dura mater corres- ponding to it is diseased, and there is a deposition of pus betwixt it and the brain, sometimes an abscess in the brain itself. Several cases of this kind are mentioned by Lieu- taud and Bonetus. Morgagni mentions a priest who, after being affected with fever, delirium, pain in the forehead, and convulsions, fell into coma, from which he was relieved by discharging rlurulent matter from the nose. A similar case, in a girl of fourteen, is mentioned by Mangetus. We are not, however, to conclude with certainty that in these cases, the discharge of matter was from the cranium, as vio- lent symptoms of the same kind have been known to occur from suppuration in the frontal sinus. This generally dis- charges itself by the nose, and the cases do well; but a case is related by Richter,* in which a suppuration within the * Observat. Chir. Fas. 2d. WITH CARIES OF THE BONES, &C 61 frontal sinus burst into the cavity of the cranium and was fatal. In other cases it makes its way outwards through the frontal bone, leaving a fistulous opening, which conti- nues to discharge matter for a considerable time before it heals. Some cases are also on record, in which worms in the frontal sinus were the source of alarming symptoms, which were relieved by the discharge of them.* In one of these, by M. Littre, there were violent convulsions. It is foreign to my plan to enter upon those important cases, in which the dura mater becomes inflamed in con- nexion with disease of the bone, arising from external in- juries. But such disease may arise in any part of the bones of the cranium without external injury, and may be pro- ductive of symptoms analogous to those already mentioned. Some years ago, a remarkable case of this kind occurred in Edinburgh, in a middle aged man, who, after a short illness, died in a state of coma. In opening the head a collection of matter was found under the temporal muscle, which communicated, through a carious perforation of the tempo- ral bone, with an abscess in the substance of the brain. Bruserius mentions a woman who, after suffering for a fort- night severe pain in the left side of the head, was seized with swelling and inflammation on the left eyebrow, eye- lids, and cheek. After several days, the swelling suppu- rated and discharged much matter, and the left eye was found to be blind; after a few days more, she was seized with convulsions, and died comatose. On dissection, the external suppuration was found to have penetrated to the bottom of the orbit, betwixt the bone and the ball of the eye, without injury of the ball itself; internally there was an extensive collection of matter which communicated freely ■with the cavity of the orbit. * See Hill's Cases in Surgery, and Hist, de l'Acad. de Science for 1708—33. 9 62 INFLAMMATION OF THE DURA MATER, In some cases of this kind, the trephine has been applied with success; and they have shown us what extent of dis- ease within the cranium may be recovered from, when a free outlet is given to the matter. Morand mentions a monk who had been for some time affected with discharge of matter from the right ear, with violent pain extending over the whole right side of the head. A tumour formed behind the ear, extending towards the temple, which, be- ing opened, was found to be an abscess, and a probe could be passed from it, through a carious opening, into the ca- vity of the cranium. The trephine was applied at this place, and discovered a suppurating cavity within the cra- nium, which discharged a tea-cupfull of matter; the dis- charge diminished gradually, and the sore was healed in two months.* M. Roux describes the case of a boy, aged thirteen, who, after a blow on the back part of the head, had a fistulous opening, which discharged matter for four years. He was liable to attacks of drowsiness and oppres- sion in the head; and these were generally relieved by co- pious discharges of matter from this opening, which was found to perforate the bone. After various treatment, the trephine was at length applied, when a small ragged open- ing was found in the dura mater, which led to a cavity un- der it, distinctly bounded by an adhesion betwixt the dura mater and the arachnoid; it discharged at the first opening about three ounces of matter, and the case terminated fa- vourably, the parts being healed in about two months.! The dura mater appears to be much less liable to idiopa- thic inflammation than the other membranes of the brain. Va- rious cases, however, are on record, in which it was affected to a considerable extent, without any disease of the bone. In a case of long continued headach, mentioned by Pawius, which * Morand Opuscules de Chirurgie. \ Nouvcau Journal de Medicine, tome xii. WITH CARIES OF THE BONES, &C 63 terminated by convulsions, the dura mater under the sagittal suture was foun^d eroded and perforated; there was also an ab- scess in the cerebellum. Rumlerus found the dura mater eroded in several places, in a young man who died comatose and convulsed. Several cases of the same kind are mention- ed in the Miscellanea Curiosa; and Haller found in several in- stances, the falx eroded by large openings, and the hemis- pheres of the brain at these places adhering to each other. As a result of inflammation of the dura mater, a circum- stance occurs in Case IV. which is worthy of notice, and which I think has hitherto been little attended to; I mean the obstruction of the lateral sinus. Of this affection, I add the following remarkable example, in which, though complicated also with disease of the bone, this affection of the sinus was the principal morbid appearance internally. Case V.—A young lady aged 16, (3d August, 1816,) com- plained of severe headach, which extended over the whole head. She had an oppressed look, and great heaviness of the eyes; pulse 120; the face rather pale. She had been liable to suppuration in the ears, and the left ear had been dischar- ging matter for three weeks; she had complained of headach for a fortnight, and had been confined to bed for two days. Blood-letting, purgatives, blistering, &c. were employed on the third and fourth with considerable temporary relief. (5th) Headach easier, some vomiting, and several severe attacks of shivering, pulse 112. (6th) Pulse 84, headach severe, now confined to the back part of the head; eyes heavy, pupils a little dilated: bleeding from the temporal artery was employed with purgatives, issue, &c. (7th) Pulse in the morning 84, and in the evening 120; headach as before, with a dull vacant look. There was a buffy coat on the blood from the tempo- ral artery. (8th and 9th) Pulse from 120 to 140; severe pain of the back of the head and neck. (10th and 11th) Pulse from 130 to 140, considerable stupor and occasional 64 INFLAMMATION OF THE DURA MATER, delirium, constant complaint of pain in the back of the head. (12th) Increase of coma, but was sensible when roused; an- swered questions distinctly, and knew those aoout her until a few minutes before her death, which happened about mid- day. Inspection.—The pia mater was highly vascular, as if mi- nutely injected; the veins on the surface of the brain were turgid, and at one place on the posterior part there was a slight appearance of extravasation of blood under the pia ma- ter. There was no serous effusion, and no disease in the substance of the brain. The left lateral sinus was remarka- bly diseased through its whole extent; when compressed, it discharged pus, and some thick cheesy matter; it contained no blood: its coats were much thickened, and its inner surface was dark-coloured, irregular,and fungous; at one part the ca- vity was nearly obliterated. The disease extended into the torcular Herophili, and affected in some degree the termina- tion of the longitudinal sinus. Behind the auditory portion of the temporal bone, near the foramen laceium, and in the course of the left lateral sinus, a portion of the bone about the size of a shilling was dark-coloured and carious on the in- ner table; it was at this place that the sinus appeared to be most diseased. The auditory portion of the bone was exten- sively carious; the cells of it were everywhere full of purulent matter, and communicated freely with the cavity of the ear. It may perhaps be doubted whether the remarkable disease of the lateral sinus which occurred in Case IV. was a recent affec- tion, and what influence it had in producing the symptoms in the fatal attack. Prichard found a similar affection of the sinus in a woman who had been epileptic for two years, and died in one of the fits without any previous change in her symptoms. He describes the left lateral sinus as being " through its whole length filled up by a substance very different from a recent co- agulum, and apparently consisting of a deposition of lymph, WITH DISEASE OF THE LATERAL SINUS. 65 which had become organized. It appeared so completely to occupy the calibre of the sinus, as to have entirely impeded the transit of blood through it." There was no other mor- bid appearance, excepting very slight effusion.* As the result of inflammatory action of a more slow and chronic kind, the dura mater is liable to thickening, and depo- sition of new matter betwixt its laminae. The following case affords an example of a very remarkable disease which ap- pears to have been produced in this manner. Case VI.—A gentleman aged 60, had been liable for two years before his death to attacks of giddiness, accompanied by complete loss of all muscular power, in which, if not prevented, he fell to the ground. In these attacks he did not lose his recollection, and he recovered completely in a few minutes. Before the commencement of this complaint, he had been liable to severe pain in the head, and giddiness, the attacks of which generally went off with vomiting. He was sound in his mind, but had considerably fallen off in flesh and strength; he felt an unsteadiness in walking, which made him afraid of going alone; and, for some months before his death, he had perceived an increasing weakness of both his lower extremi- ties. On the first of August, 1816, he was attacked with he- miplegia of the left side, accompanied by headach and giddi- ness; the pulse was natural, and his mind was not affected. For four days he continued to be affected with the most com- plete hemiplegia; he then began to recover a little motion of the parts, and about the 15th was able to raise his arm to his head, and to walk a little with assistance; he still complain- ed of giddiness, and noise in his ears, but had little headach. Blood-letting and the other usual remedies had been employ- ed. On the 19th, there was considerable headach; on the * Prichard on Diseases of the Nervous System, p. 175. 66 INFLAMMATION OF THE DURA MATER, 20th, he became incoherent: and on the 21st, fell into perfect coma, with some convulsion. On the 22d, he was considera- bly recovered, so as to know those about him, and to answer questions rationally; but at night he relapsed into coma, and died on the 23d. For the last three days his pulse had been from 112 to 120. Inspection.—Along the upperpartofthe right hemisphere of the brain, there lay a remarkable tumour five and a half inches long, two and a half broad, and about half an inch in thickness; it was formed by a separation of the laminae of the dura mater and a deposition of new matter betwixt them. This new matter was, at the posterior part, white and firm; in other places, es- pecially about the centre of the tumour, it was more recent co- agulable lymph, firm, yellow, and semi-transparent; and, at the anterior part, there was a cavity containing yellowish serous fluid. The tumour lay from before backwards along the upper part of the hemisphere,—the inner edge of it being about an inch from the falx; the dura mater all around it was conside- rably thickened, as were also the coats of the longitudinal si- nus. The surface of the brain, where the tumour lay, was de- pressed so as to retain an impression of its figure; and, on the anterior part of the brain, the substance was considera- bly softened, with some appearance of suppuration. There was very little serous effusion, and no disease in any other part of the brain. I have found nothing described by any writer precisely similar to this remarkable aflection. The case most nearly resembling it in the symptoms, is one described by Lanci- sius.* The attacks in this case consisted of paroxysms, which appeared to be a mixture of syncope and apoplexy; sometimes accompanied with hemiplegia, and sometimes with convulsion. The pia mater was found remarkably * Lancisius de Subitaneis Mortibus. CHRONIC, WITH REMARKABLE THICKENING. 67 thiekened and covered with a kind of ill-conditioned pus. Willis found a remarkable thickening of the dura mater at the base of the brain, in a young woman who had been lia- ble to severe headach, aggravated at the menstrual period; and at these times accompanied by distortion of the neck to one side; she was likewise liable to attacks of vertigo and lipothymia, and died comatose. Similar cases are mentioned by Morgagni. A boy aged six, whose case is mentioned by Mr. Paisley,* was seized with pain on a particular spot on the left side of the head, followed by drowsiness; which proved fatal on the 12th day, with the usual symptoms of hydrocephalus. On the part corresponding to the seat of the original pain, there was a tumour the size of a large hazel- nut, formed by a separation of the laminse of the dura ma- ter, and the deposition betwixt them of a bloody serous fluid. There were several similar tumours, but of smaller size along the course of the longitudinal sinus on the left side. Besides the fluid, the tumours contained a number of small white bodies like worms; at the places where the tumours were formed, the dura mater adhered very firmly to the membranes beneath. There was much effusion under the arachnoid and in the ventricles. SECTION IV. INFLAMMATION OF THE ARACHNOID AND PIA MATER. Inflammation of the arachnoid, and of the pia mater, may be taken together. It is very difficult to distinguish them in practice, and as the affections are generally com- bined, it is probable that no important purpose can be an- * Edinburgh Medical Essays, vol. iii. 68 inflammation of arachnoid and pia mater.' swered by attempts to discriminate between their symp- toms. The disease terminates most commonly by a depo- sition of false membrane betwixt the arachnoid and the pia mater. When this is found to spread uniformly over the surface of the convolutions, we may suppose that it has been produced from the arachnoid; when it dips considerably be- tween them, it is probable that the pia mater has been affect- ed; but, in point of fact, it is very often remarked in these cases, that the pia mater presents a most intense degree of vascularity, even when there is no deposition betwixt the convolutions, while there is seldom any remarkable vascu- larity observed in the arachnoid. On this ground it has sometimes been doubted whether the arachnoid be really the seat of inflammation. Some degree of this affection frequently accompanies other acute diseases of the brain, but we very often find it entire- ly uncombined, so that we are enabled to mark the symp- toms more immediately connected with it. In these, how- ever, there does not appear to be any uniformity. In some cases, it comes on with headach, vomiting, fever and im- patience of light; but I think the more common form in which the attack takes place, is by a sudden and long con- tinued paroxysm of convulsion. This is in some cases pre- ceded by headach and vomiting, but in other cases comes on without any warning. The convulsion is generally long and severe; in some cases, it passes immediately into coma, which afterwards alternates only with a repetition of the convulsion, until in a few days the case is fatal. In other cases, there is recovery from the first convulsion, and the patient appears to be doing well for some time, perhaps for several days, but afterwards falls into coma, either with or without a recurrence of the convulsion. In other cases again, the convulsion does not come on till an advanced pe- riod of the disease. MENINGITIS. 69 The following selection of cases will illustrate the princi- pal phenomena connected with this important affection, both in children and in adults. To prevent circumlocution, I shall employ the term Meningitis to express the disease, meaning thereby the inflammation of the arachnoid, or pia mater, or both, as distinct from inflammation of the dura mater. § I.—Simple meningitis in the most common form. Case VII.—A boy aged 11, had been for about a fort- night remarkably listless and inactive, and affected with fre- quent vomiting. The vomiting had occurred every day, or several times in the day; his bowels were costive, but he did not complain of any pain, and he was free from fe- ver. In the evening of the 29th June, 1816, he was seized with violent convulsion, which recurred several times; in the intervals he had severe vomiting, and complained of headach; pulse 60. The convulsion occurred frequently during the following night, and in the intervals he com- plained that he could not see. Towards morning, the con- vulsion ceased, and left him in a state of the most profound coma. The coma continued till mid-day of the 30th, when it began to abate after he had been freely purged; in the evening he was quite sensible, and complained of headach; pulse 120. July 1st.—The ordinary remedies having been adopted, he was much relieved; no headach; no vomiting; tongue moist; pulse 120. 2d.—Pulse 108; no complaint; much disposed to sleep; pupils rather dilated. 3d.—Pulse 112; appearance much improved; eye natu- ral; bowels open; tongue clean; no unusual drowsiness. 4/A.—Pulse 108; functions natural; a good deal disposed to sleep. 10 70 MENINGITIS. 5th.—Pulse 70; had an attack of vomiting, and com- plained much of his head; afterwards fell into a degree of stupor; was sensible when roused, but was impatient of be- ing disturbed, and still complained of his head; eyes natu- ral; repeated vomiting. Mh.—Perfect coma, with frequent convulsion; pulse from 120 to 160; he frequently lay with the one hand press- ing his forehead, and the other on the occiput. 1th.—In profound coma the whole day; died during the night. Inspection.—On raising the dura mater, the surface of the brain in many places had a yellow appearance, which was found to arise from extensive deposition of adventitious membrane under the arachnoid. It was in general about the thickness of a wafer; some portions of it were thicker, and in some places masses of it of considerable extent lay betwixt the convolutions. There was also a good deal be- twixt the hemispheres, which were partially glued together by it. The principal seats of this deposition were, the an- terior part of both hemispheres, and the whole base of the brain, especially the depressions betwixt the lobes; and it also covered nearly the whole surface of the cerebellum. On the posterior part of the brain it was wanting, and there the pia mater was evidently inflamed. The surface of the brain, at these places, had also an inflamed appearance, but this did not penetrate into its substance. Some fluid was found in the base of the cranium, after the brain was re- moved, but there was no effusion in the ventricles, and the brain in other respects was healthy. Case VIII.—A girl, aged 9, awoke suddenly in the night of 20th September, 1817, screaming from violent headaoh, and exclaiming that some person had given her a blow on the head., MENINGITIS. 71 21st.—She complained of pain in the forehead, but she was not in bed, and the pain was not severe. 22d.—Little change; partly in bed, and complaining of headach, but the complaint excited no alarm. 23d.—Was seized with violent and long continued con- vulsion, which was immediately succeeded by profound coma. 24th.—I saw her for the first time; found her in perfect coma; the eyelids open, the eyes distorted upwards, the pulse quite natural. Continued in the same state on the 25th, and died on the 26th. Inspection.—On removing the dura mater, the other membranes appeared highly vascular as if inflamed, except where this appearance was concealed by a layer of yellow adventitious membrane, spread out betwixt the arachnoid and the pia mater. This deposition was distributed in ir- regular patches, over various parts of the surface of the brain, but was most abundant on the upper part of the right hemisphere. It was in general of the thickness of a wafer, and in some places extended downwards betwixt the con- volutions. There was also a considerable quantity of it on the surface of the cerebellum. There was a good deal of gelatinous effusion about the optic nerves, and about an ounce of eolourless fluid in the ventricles. The substance of the brain was throughout unusually vascular. Case IX.—A child aged 2 years, 21st May, 1826, was suddenly seized in the morning with severe and long con- tinued convulsion. It left her in a dull and torpid state, in which she did not seem to recognise the persons about her. She had lain in this state for several hours, when the con- vulsion returned; and, during the following night, it re- curred a third time, and was very severe and of long con- tinuance. I saw her on the morning of the 23d, and while I was sitting by her, she was again attacked with severe 72 MENINGITIS. and long continued convulsion, which affected every part of the body, the face and the eyes in particular being fright- fully distorted. The countenance was pale, and expressive of exhaustion, the pulse frequent; her bowels had been free- ly opened by medicine, previously prescribed by Dr. Beil- by, and the motions were dark and unhealthy. Farther purging was employed, with topical bleeding, cold applica- tions to the head, and blistering. After this attack, she continued free from convulsion till the afternoon of the 23d; in the interval she had remained in a partially comatose state, with frequent starting, pulse frequent, but feeble, pu- pil rather dilated; she took some food. In the afternoon of the 23d, the convulsion returned with great severity; and on the 24th, there was a constant succession of paroxysms, during the whole day, with sinking of the vital powers; and she died early in the evening. Inspection.—On removing the dura mater, the surface of the brain appeared in many places covered by a deposi- tion of adventitious membrane, betwixt the arachnoid and pia mater. It was chiefly found above the openings betwixt the convolutions, and in some places appeared to dip a lit- tle way betwixt them. The arachnoid membrane when detached appeared to be healthy, but the pia mater was throughout in the highest state of vascularity, especially betwixt the convolutions; and when the brain was cut ver- tically, the spaces between the convolutions were most strikingly marked by a bright line of vivid redness, pro- duced by the inflamed membrane. There was no effusion in the ventricles, and no other morbid appearance. § II.—Meningitis of unusually great extent, with very obscure symptoms. Case X.—A child aged between 3 and 4, had scarlatina mildly in the middle of June 1824, having been confined only MENINGITIS. 73 four or five days. He had been down stairs for several days, and once or twice out of doors; when, on the evening of the 23d, he became feverish, and complained of his bowels. After the operation of some laxative medicine he was much relieved on the 24th; his pulse, however, continued frequent. On the 25th, he again complained of his bowels, and was fever-- ish; but in the evening he was again relieved, and no symp- tom was remarked by Mr. White, except that his pulse con- tinued slightly frequent, and at one time he complained of uneasiness in his eyes. In the night he was restless, but still complained only of his belly; his bowels had been freely moved, and the motions were natural. On the 26th, he had frequent vomiting, and in the evening became oppressed; pulse 120. I saw him for the first time at night. He was then in a state of oppression, evidently verging towards coma; could be roused, but without taking much notice of objects; pulse 120; countenance and eye natural. Topical bleeding, pur- gatives, cold applications, &c. were employed. In the night there was frequent vomiting, every medicine being brought up, and the bowels were not moved. On the 27th, the coma was increased, and there were through the day frequent con- vulsive affections of the face and arms; pulse 120, and weak; pupil dilated, and the eye insensible; died early in the morn- ing of the 28th. Inspection.—On removing the dura mater, the whole sur- face of the brain was found to be covered by a continued stratum of yellow adventitious membrane, deposited betwixt the arachnoid and pia mater. It was thickest above the openings betwixt the convolutions; in many places, it was traced dipping betwixt them to the depth of half an inch; and in some places, on the right side of the brain, it followed the course of the pia mater through the whole depth of the con- volutions. The deposition was general over the whole brain, and on the upper and anterior parts. of the cerebellum; and there was a good deal of it about the optic nerves. The pia 74 MENINGITIS. mater and the arachnoid adhered every where very firmly together by means of it; when they were separated, the arach- noid presented no unusual appearance, but the pia mater showed throughout the highest degree of vascularity; the de- position was entirely confined to the space betwixt the mem- branes, for no vestige of it could be traced either on the outer surface of the arachnoid or the inner surface of the pia mater. There was no serous effusion, and the brain and the cerebel- lum were perfectly healthy; the bowels were in many places irregularly distended with flatus. § III.—Meningitis of very small extent, with severe SYMPTOMS. Case XI.—A child aged 6 years, 24th January, 1822, had severe headach and some vomiting, followed by extreme ob- stinacy of the bowels, which resisted the most active medi- cines for six days. During this time, she complained con- stantly of headach, and the vomiting recurred from time to time, but was not severe, the pulse varying from 90 to 100. General and topical bleeding, with the most active purgatives and injections, had been employed with every possible assi- duity by Dr. Hay. On the 6th day, the bowels began to yield, and about the 10th, there was a remarkable improve- ment of all the symptoms, pulse from 80 to 90, and the head- ach nearly gone. This favourable state continued for two days; the headach then returned, and on the following day, the 13th of the disease, considerable hesitation of speech was observed, with slight delirium occurring at intervals. On the 14th, she was in these respects better, but still complained of headach, which was referred to the forehead; pupils dilated; pulse frequent. On the 15th, slight convulsion was remarked several times through the day, and the pain of the forehead was still complained of. On the 16th, she was in the morn- MENINGITIS. 75 ing distinct and intelligent, but still complained of headach; pulse 120. Through the day, the pulse varied from 90 to 140, the pupil was dilated, and the vision imperfect, but she con- tinued quite intelligent till eight o'clock in the evening; she was then seized with severe convulsion, which continued without intermission for two hours, when she died. This very important case was most minutely attended to through its whole course, and all the usual remedies were employed in the most active manner. Inspection.—There was no effusion in the ventricles, and every part of the brain presented the most healthy appear- ance, except a small part on the lower surface of the anterior lobe of the right hemisphere, where it lies over the orbit. There was, at this place, a distinct deposition of adventitious membrane of an extent scarcely larger than a shilling. Im- mediately connected with it, the substance of the brain was sensibly hardened, to an extent corresponding to the size of a large nut. No other disease could be discovered in any organ. § IV.—Meningitis of the base. Case XII.—A young lady, aged 14, was affected with symptoms resembling those of mild continued fever, which excited no alarm till about the end of the second week, when the headach became more severe, with some oppression, and transient incoherence. I saw her, for the first time, in the beginning of the third week; there was then a degree of op- pression, tending to coma; the pupil was dilated; pulse from 110 to 120; the tongue foul. For some days the symptoms varied considerably; sometimes showing a degree of coma, but generally rather exhibiting the characters of typhus. The eyes, however, appeared to be insensible to the light, and once or twice a degree of squinting was observed, but it went off; sometimes she answered questions distinctly, and some- 76 MENINGITIS. times not; the pulse varied from 110 to 130. On the day be- fore her death, she was much more sensible, and upon the whole considerably relieved; but next day she was more co- matose, and her strength was sinking; and she died at night, about three weeks from the commencement of the disease. Several of the family had died of hydrocephalus. Inspection.—The substance of the brain was healthy; the ventricles contained about two ounces of fluid; there was a considerable deposition of adventitious membrane on the sur- face of the Pons Varolii, which extended forward along the base of the brain; there was a good deal of it in a more re- cent state about the optic nerves, and it was thence traced upwards betwixt the thalami towards the third ventricle. § V.—Meningitis with suppuration on the surface. Case XIII.—A child, aged 8 months, died 13th March, 1818, of an illness which had continued more than 3 weeks. It began with fever, restlessness, and quick breathing; after- wards there were frequent convulsive affections, with much oppression, and at last severe convulsions, squinting and coma. At an early period of the complaint, there was observed a re- markable prominence of the anterior fontenelle; in the second week, this increased considerably; and in the third week, it was elevated into a distinct circumscribed tumour, which was soft and fluctuating,—and pressure upon it occasioned con- vulsion. It was opened by a small puncture, and discharged at first some purulent matter, afterwards bloody serum. No change took place in the symptoms, and the child died four days after. Inspection.—The opening which had been made through the fontanelle, was found to lead to a deposition of thick floc- culent matter mixed with pus, betwixt the dura mater and the arachnoid, and covering the surface of the brain to a con- meningitis. 77 siderable extent. There was a similar deposition betwixt the arachnoid and the pia mater, which extended between the convolutions, and there was a good deal of it about the optic nerves and under the medulla ohlongata; there was consider- able effusion in the ventricles. § VI.—Meningitis with suppuration within the VENTRICLES. Case XIV.—A child, aged 5 months, previously in per- fect health, was seized with convulsion on the evening of the 21st November, 1817. The attack, which was not of long duration, was ascribed to dentition; the gums were di- vided over several teeth that appeared to be producing irri- tation, and the other remedies were employed that are usual in such affections. He continued well through the night; on the 22d, he was oppressed, with quick breathing, and in the afternoon, without any return of convulsion, he fell into a state of coma. This continued several hours, and then subsided, after topical bleeding, active purging, and the use of cold applications to the head. On the 23d, he was much relieved; eye natural; he took notice of objects, and was disposed to play, and no complaint was remarked, except occasional starting. On the 24th, he continued through the day in the same favourable state; but late at night he was seized with convulsion, which continued without intermis- sion through the night, and he died early in the morning. Inspection.—There was an extensive deposition of ad- ventitious membrane betwixt the arachnoid and pia mater; it covered a great part of the upper surface of the brain, and there was a considerable quantity of it on the inferior surface of the anterior lobes, betwixt the hemispheres and on the cerebellum. In the lateral ventricles, there was 11 78 MENINGITIS. about an ounce of purulent matter, and the substance of the brain surrounding the ventricles was very soft; there was no serous effusion. There was much gelatinous deposition about the optic nerves, under the base of the brain, and un- der the cerebellum. Below the medulla oblongata, there was a similar deposition mixed with some purulent matter. § VII.—Meningitis of the cerebellum. Case XV.—A lady, aged 45, liable to suppuration of the left ear, complained of pain in that ear, May 11, 1821. On the two following days, the pain extended through the head with fever; and on the 14th, she complained of gene- ral headach, and a violent and painful feeling of throbbing in the back part of the head. She was deaf, and inclined to drowsiness, but quite sensible; pulse 120 and very strong; large blood-letting and the other usual remedies were active- ly employed on this and the following days by Dr. Thatch- er and the late Mr. Bryce. I saw her on the 16th; there was then a good deal of coma, but she was sensible when roused; the eye natural, the tongue clean, pulse 130; she still complained of headach when she was closely questioned, but did not make any complaint except when she was much roused. The pulse being now considerably reduced in strength, topical bleeding only was employed. In the eve- ning she was more easily roused, and said she felt better; in the night she became again extremely restless and inco- herent, and died early in the morning. There had been a slight discharge of matter from the left ear early in the dis- ease. Inspection.—There was slight effusion in the lateral ven- tricles; the brain in other respects was healthy. On the outer surface of the cerebellum there was a uniform depo- sition of thick puriform matter; it was most abundant on MENINGITIS. 79 the left side. The pia mater of the cerebellum was highly vascular, the dura mater was healthy; there was some pu- rulent matter about the pituitary gland, and in the cavity of the ear, but there was no appearance of disease of the bones connected with the ear, or of the dura mater covering them. TJncombined meningitis of the cerebellum seems to be an uncommon affection. An interesting example of it is men- tioned by Mr. Duglisdn in the London Medical Reposito- ry. A boy aged 5, pale and delicate, after being slightly indisposed for four or five days, was seized in the night of 9th August with violent convulsion. On the 10th, there was fever with delirium: a vacant look of the eye, and an evident imperfection of vision, which appeared by his at- tempting to lay hold of objects that were presented to him, and missing them. There was dilated pupil and slight strabismus. 11th, 12th, 13th, and 14th, Symptoms gradu- ally increasing; 15th, coma; constant motion of the right arm and leg; the left appeared to be paralysed. In the night was seized with violent convulsion, which continued till his death; this took place on the morning of the 16th. The brain was healthy. There was a remarkable vascula- rity on the tuber annulare, forming a thick web of vessels. It was connected with the arachnoid coat of the right side of the cerebellum, which was thickened with some deposi- tion of coagulable lymph. About ^iv. of fluid was found in the base of the skull, but not above a tea-spoonful in the ventricles. These cases will serve to illustrate the remarkable diver- sity of symptoms which accompany this affection. I have selected them as calculated to exhibit the pure meningitis unconnected with any other considerable disease of the brain. The convulsive affections of children, which are 80 meningitis. apt to be indiscriminately ascribed to dentition, are, I think, frequently connected with this disease. In such cases, in- stead of the deposition of adventitious membrane, we fre- quently observe a thin but extensive coating of puriform fluid on the surface of the pia mater. § VIII.--A DANGEROUS MODIFICATION OF THE DISEASE WHICH SHOWS ONLY INCREASED VASCULARITY. Another important modification of the disease occurs in an insidious and highly dangerous affection, which I think has been little attended to by writers on the diseases of the brain. It is apt to fie mistaken for mania, or, in females, for a modification of hysteria; and in this manner the dan- gerous nature of it has sometimes been overlooked, until it proved rapidly and unexpectedly fatal. It sometimes com- mences with depression of spirits, which after a short time passes off very suddenly, and is at once succeeded by an unusual degree of cheerfulness, rapidly followed by mania- cal excitement. In other cases, these preliminary stages are less remarkable; the affection, when it first excites at- tention, being in its more confirmed form. This is in ge- neral distinguished by remarkable quickness of manner, ra- pid incessant talking, and rambling from one subject to ano- ther, with obstinate watchfulness, and a small frequent pulse. Sometimes there is hallucination or conception of persons or things which are not present, but in others this is en- tirely wanting. The progress of the affection is generally rapid; in some cases it passes into convulsion and coma; but in general it is fatal by a sudden sinking of the vital powers, supervening upon the high excitement, without coma. The principal morbid appearance is a highly vascular state of the pia mater, sometimes with very slight effusion betwixt it and the arachnoid. The disease is one of extreme MENINGITIS. 81 danger, and does not in general admit of very active treat- ment. General bleeding is not borne well, and the treat- ment must in general be confined to topical bleeding with purgatives, antimonials, and the powerful application of cold to the head. The affection is most common in females of a delicate irritable habit, but also occurs in males, espe- cially in those who have been addicted to intemperance. I have however seen it in one case, in a gentleman between 40 and 50, of stout make and very temperate habits. The cause of death is obscure; it seems in general to be a sudden sinking of the vital powers, supervening upon the high excitement without any of the actual results of inflamma- tion. Case XVI.—A lady, aged 23, had suffered much dis- tress from the death of a sister, and been affected in conse- quence with impaired appetite and want of sleep; this had gone on for about two months, when on the 4th of August 1825, she sent for Dr. Kellie, and said she wished to con- sult him about her stomach. He found her rambling from one subject to another with extreme rapidity and considera- ble incoherence; and on the 5th, she was in a state of the highest excitement, with incessant talking, alternating with screaming and singing; pulse from SO to 90. In the eve- ning, she became suddenly calm and quite sensible after an opiate; continued so for an hour or more, then fell asleep, and after sleeping two hours, awoke in the same state of ex- citement as before. The same symptoms continued on the 6th; the pulse in the morning was little affected: but after this time it became small and very rapid. On the 7th, af- ter a night of great and constant excitement, she had ano- ther lucid interval, but her pulse was now 150. The ex- citement soon returned, and continued till four in the after- noon, when she fell asleep. She awoke about eight, calm and collected, but with an evident tendency to coma; pulse 82 MENINGITIS. 150, and small. She now took food and wine, and passed the night partly in a state of similar excitement, and partly comatose; and died about mid-day of the 8th, having con- tinued to talk incoherently, but knowing those about her, and in general understanding what was said to her. Inspection.—The only morbid appearance that could be discovered was a highly vascular state of the pia mater, with numerous red points in the substance of the brain. Case XVII.—A gentleman, aged 44, of a stout make, and very temperate habits, became suddenly affected, with- out any known cause, with extreme depression of spirits, accompanied by a good deal of talking and want of sleep. After this condition had continued for two days, it went off suddenly, and he recovered excellent spirits and talked cheerfully. This however was soon succeeded by a state of excitement, with rapid incoherent talking, and obstinate watchfulness; and the pulse rose rapidly to 160. This state continued without abatement for about four days, when he suddenly sunk into a state of collapse and died. Inspection.—The only morbid appearance was a highly vascular state of the pia mater and arachnoid, with slight serous effusion betwixt them. This obscure and dangerous affection is sometimes met with in connexion with other diseases, especially acute rheumatism and other inflammatory affections, and some- times attacks females in the puerperal state. It is unneces- sary to give a lengthened detail of cases which do not tend to throw any additional light upon the nature of it. A young lady whom I saw with Mr. Turner, had acute rheumatism in a very slight form for three days, her pulse from 90 to 96; on the fourth day, the pain ceased, and in the evening, she began to talk a greatdeal and rather incoherently, but MENINGITIS. 83 made no complaint. On the 5th day, she was more tran- quil, but at night the incoherent talking returned. I then saw her for the first time; she was talking a greatdeal, wild- ly and incoherently, but, when her attention was arrested, she answered questions distinctly; the pulse was 120; the tongue rather loaded, but moist; and she did not complain of any uneasiness. On the sixth day, these symptoms con- tinued; in the evening she became comatose, and died in the night. Blood-letting was employed, and various other remedies, without benefit. A soldier aged 34, for whose case I am indebted to the late Dr. Hennen, had acute rheu- matism in a severe form, combined with pneumonic symp- toms. He was relieved by blood-letting, but his pulse con- tinued frequent, and he had some palpitation of the heart, but not severe. On the fifteenth day of the disease, he be- came suddenly comatose, and died in a few hours. In both these cases the appearances on dissection were altogether unsatisfactory. The above remarks on this highly dangerous and interest- ing affection, I leave as they stood in the first edition of this work. Since that time I have seen several examples of it, and have been induced to adopt a different mode of treatment, which seems to promise some interesting results. Without at present venturing upon any general conclusions, I shall merely submit the following case. Case XVIII.—A lady, aged about 38, was recovering from her eleventh accouchement, when, at the end of a fortnight, she became affected with a deep-seated hard swelling in the right side of the pelvis, which was tender to the touch, and was accompanied by a considerable degree of fever. After repeated topical bleeding and other remedies, the febrile state subsided, the swelling lost its tenderness, and seemed to be gradually diminishing in size; but its progress was very slow, S4 MENINGITIS. and after three or four weeks, she was still confined to bed, and suffering a good deal of uneasiness; her pulse was now calm, but she was considerably reduced in strength. At this time, she became, one day, alarmed and agitated by some fa- mily occurrence, and immediately began to talk wildly and in- coherently, and after a restless night was found next day in a state of the highest excitement, talking incessantly, scream- ing and struggling, with a wild expression of countenance, and a small rapid pulse. She was treated by topical bleeding, laxatives, cold applications to the head, &c, but with little or no benefit; and on visiting her on the following day, I found her sitting up in bed, with a look of extreme wildness, both her hands in constant motion, talking incessantly and wildly; and I learnt that she had not ceased talking for one instant for the last twelve hours. Her pulse was now rapid and feeble, and her countenance expressive of exhaustion. In consultation with a highly intelligent friend who had charge of the case, I mentioned my experience of the fatal nature of the affection, and proposed to make trial of treatment by stimulants. A glass of wine was accordingly given, with evident abatement of the symptoms; and it was ordered to be repeated every hour. At the end of the fourth hour, she was perfectly com- posed and rational, her pulse about 90 and of good strength; and from this time there was no return of the symptoms. The tumour in the right side increased in size, suppurated, was opened and healed favourably. From this time she continued in perfect health, and has since passed through another ac- couchement in the most favourable manner. This case I have given as another example of this interest- ing affection. I have employed the same mode of treatment, with similar benefit in several other cases, both of males and females. The chief difficulty is in deciding upon the particu- lar cases to which the stimulating treatment is applicable. They appear to be those in which the excitement is accompa- nied by small and rapid pulse, and an expression of paleness MENINGITIS. 85 and exhaustion. When these characters are present, howe- ver violent the excitement may be, I have not been deterred from the practice, and in a considerable number of instances have found much reason to be satisfied with it. I have tried it, but without the same benefit, in some of the common cases of insanity, accompanied by paleness and bodily weakness, but with a natural pulse. When there is frequent and strong pulse, with flushing, and other marks of increased vascular action, it would of course be injurious. An affection occurs in children which presents the same obscurity in the morbid appearances as in these remarkable cases, though with different symptoms. The child is gene- rally attacked with a succession of convulsions, and is cut off within various periods, from one to three or four days. It is apt to occur in connexion with other diseases, especially hooping-cough. Case XIX.—A child, aged two and a half years, affected with hooping cough in a very mild form, was attacked, in the end of May 1822, with a convulsive twisting of the hands, to which she had been formerly liable at an early period of life: this excited no alarm, till the 4th of June, when she was seized with general convulsion, accompanied with fever, headach, and an obstinate state of the bowels. All the usual remedies were employed with activity, but the convulsions continued to recur several times in the day, and she died on the 8th. The cough had gone on, but in a mild and favourable form. Inspection.—There was slight increase of vascularity of the pia mater, with numerous red points throughout the me- dullary substance of the brain. No other disease could be discovered on the most careful examination, and all the other organs were healthy. Case XX.—A child, aged 5, affected with hooping-cough, 12 86 MENINGITIS. on 5th June, 1822, was seized with headach and fever; had afterwards irregular motion of the eyes, with occasional squint- ing, then violent convulsions, which recurred frequently and alternated with coma; and he died in three days. After death, nothing could be discovered, on the most careful examination, except increased vascularity of the pia mater in several places. Case XXI.—A child, aged three years and a-half, had been for several days slightly feverish, with some cough, but the complaint was considered, as trifling, and she was sitting at table on the evening of 3d April, when she suddenly lost her speech, and soon afterwards was seized with general convul- sion. She continued in a state of constant and violent con- vulsion, with complete insensibility, for several hours; in the course of the night the convulsion abated—she recovered the power of swallowing, which had been lost, and took purgative medicine, which operated powerfully. On the 4th, the con- vulsion returned with great violence; she had a constant suc- cession of paroxysms, during the day, and in the intervals was in a state of coma. She died early on the 5th. On inspec- tion, no disease could be discovered, except increased vascu- larity of the membranes of the brain, and turgidity of the veins upon the surface. I have notes of several cases resembling this in the symp- toms, and presenting the same obscurity in the morbid ap- pearances. They occurred in strong healthy children from two to four years of age, and were fatal generally about the third day, and under various modes of treatment. It is unnecessary to multiply examples of this kind, which only serve to show us the imperfection of our knowledge on the pathology of the brain. In the following singular case, the affection here referred to seemed to have taken place in the course of another disease of the brain, and to have been MENINGITIS. 87 the immediate cause of death, before the primary affection had been so far advanced as to have the nature of it distinctly characterized. » Case XXII.—A child, aged four years, of a family who had lost many children from various forms of disease, had been affected for about ten or twelve days with a feverish dis- order, which had not shown any alarming symptom. The complaint appeared to be subsiding, and, on the day on which he died, he had been considered as convalescent by two me- dical men of the first eminence. In the afternoon of that day, his mother observed that his eyes became suddenly fixed and vacant. Soon after, he was seized with most violent general convulsion, which continued, without intermission, for about five hours, when he died. Inspection.—There was considerable effusion in the ven- tricles, and a good deal of ramolissement of the septum and fornix. The only other morbid appearance was a most ex- tensive and high degree of vascularity of the pia mater. Inflammation of the arachnoid and pia mater appears to occur in a more chronic form, in which it may go on for a considerable time, spreading from one part of the brain to another, and producing a succession of symptoms, as the parts become successively affected. A lady, mentioned by Mr. Howship,* had severe headach, impatience of light, and pa- ralysis of the left arm and leg. After a short time the para- lysis was removed, but the arm continued so painful as to be nearly useless. The pain of the head continued, and, after two months, extended downwards upon the neck and back. She had then retention of urine, severe throbbing pain of the back and loins, convulsive contraction of the shoulders, and * Howship's Practical Observations in Surgery and Morbid Anatomy. 88 MENINGITIS. pain shooting through from the back to the breast. She had at last intense pain in the head, neck, back, and whole body, so as to be unable to move a single limb, and died gradually exhausted, four months aft^r the commencement of the dis- ease. On inspection, serous effusion was found under the arachnoid, with extensive deposition of coagulable lymph on the upper, lateral, and inferior parts of the brain, and the an- terior part of the medulla oblongata: and the same disease was found to have extended along the membranes of the spinal cord. Chronic disease of the pia mater and arachnoid is met with in various forms; in some cases, consisting of thickening of the membranes themselves; in others, with old depositions of false membranes; and in some, the affection is complicated with tubercular disease of the pia mater. A gentleman mentioned by Dr. Powel,* after having been affected for a fortnight with slight headach, became incohe- rent, with a considerable degree of stupor, dilated pupils and indistinct articulation; and he died in another fortnight. The pupil of the right eye was more dilated than that of the left, and, a short time before his death, the right side became pa- ralytic. On inspection, effusion was found in the ventricles, and deposition of coagulable lymph about the pons Varolii. At the anterior part of the middle lobe of the brain—he does not say in which hemisphere—the pia mater was much thick- ened, and its inner surface was studded with small tubercles, like large pin-heads. Similar tubercles were observed in other parts of it especially where it lies betwixt the convolutions. This tubercular disease of the pia mater does not appear to be a common affection, but a very remarkable case of it is mentioned by Dr. Clark.t A man, aged 35, addicted to in- toxication, was seized with fever and cough, followed by vo- • Transactions of the College of Physicians of London, vol. v. f Edinburgh Medical Journal, vol. v. p. 261. MENINGITIS. 89 mi ting, bloody stools, drowsiness, and muttering; but he was not entirely confined for the first fourteen days; after this he became worse, with severe headach, much cough, subsultus, drowsiness and deafness, pulse 116, tongue dry and brown. He had then delirium, impatience of light, and a degree of coma; but he was relieved by bleeding, and the pulse fell to 96. He died suddenly on the 24th day, having been out of bed and eating heartily the day before. On inspection, the dura mater was found perforated by small orifices, which transmitted flesh-coloured tubercles. These appeared to arise from the pia mater, and had no connexion with the brain; some of them were of the size of small peas, and were re- ceived into depressions of the cranium, some of which were one-sixth of an inch in depth. The arachnoid was thickened, and in some places adhered to the pia mater; in other places, coagulable lymph was deposited betwixt them; there was some fluid in the ventricles. Thickening of the membranes and adhesions to each other are met with in many cases, probably the result of inflamma- tory action of old date. Such cases are mentioned by Wep- fer, Willis, and others, in some of which the patients had been long liable to headach. Similar appearances have been ob- served in old maniacal cases. A man is mentioned by Dr. Powel, who had been two years insane, and died fatuous; he had been liable, at uncertain intervals, to convulsive attacks, in which the left side of the body suffered more than the right. An adventitious membrane of the thickness of three sheets of writing paper, was found covering the whole right hemisphere of the brain; it became thinner on the lower parts of it, and was gradually lost at the base; the left hemisphere was entirely healthy. 90 INFLAMMATION OF THE SECTION V. , INFLAMMATION OP THE SUBSTANCE OF THE HEMISPHERES. In the symptoms accompanying inflammation of the sub- stance of the brain there are considerable varieties, depend- ing probably on the extent of the disease, and the particular part of the brain which is the seat of it. We find in some cases, headach, followed by high delirium, and this by coma; in others, a sudden attack of convulsion. A frequent and very important form of the disease is characterized by head- ach, followed by convulsion of one or more limbs, the affect- ed limbs afterwards becoming paralytic. Other cases again assume a close resemblance to the ordinary attack of hemi- plegia, so as scarcely to be distinguished from it; and a very interesting feature of the affection in these cases is, that the disease in the brain may not have extended beyond the state of simple inflammation, though the symptoms have passed through their usual course, and have terminated in fatal coma. In the progress of the disease, considerable modifications occur, arising from the various ways in which the inflamma- tion terminates; in these we are chiefly to attend to the fol- lowing varieties. I. It may be fatal in the inflammatory stage;—a cer- tain defined portion of the cerebral substance presenting the appearance of deep redness without any change of structure. II. The simple ramollissement; which consists in a part of the brain'being broken down into a soft pulpy mass, re- taining the natural colour of the part, without any appearance of suppuration, and without fetor. This condition we often find as the only morbid appearance, but we frequently find it combined with the former, one portion of the diseased mass presenting the deep red colour, while another is in the state of ramollissement. SUBSTANCE OF THE HEMISPHERES. 91 III. The preceding appearance mixed with a proportion of purulent matter. IV. The undefined suppuration. This might perhaps be considered as a modification of the former, but with the purulent matter predominating in quantity. It presents a large ragged undefined cavity, filled partly with fetid puru- lent matter, and partly with broken down cerebral substance, the surrounding substance being soft and disorganized. V. The defined or encysted abscess. This consists of a well defined regular cavity, filled with purulent matter, gene- rally lined by a soft cyst, and surrounded by cerebral matter in a healthy state. VI. Ulceration of the surface of the brain. Important modifications also occur in connexion with the character of the disease in regard to activity. In particular, there appear to be some very interesting phenomena, con- nected with a chronic form of it, in which it may continue for a considerable time without advancing to a fatal termina- tion, or in which the symptoms may remit so as to assume a periodical character. These various modifications will be illustrated by the following selection of cases. § I.--THE INFLAMMATION OF THE CEREBRAL SUBSTANCE FATAL IN THE INFLAMMATORY STAGE. Case XXIII.—A woman, aged 26, had laboured under bad health in a variety of forms for 18 months before her death. Her complaints began with severe headach, and fre- quent attacks of convulsion. After some time, these symp- toms subsided, and she was seized with cough, hemoptysis, quick and laborious breathing, and scarcity of urine. The affection of her breathing came on in paroxysms, during which her respiration was 80 or 90 in a minute, and sometimes con- tinued in this state for several days together, her pulse being 92 INFLAMMATION OF THE HEMISPHERES. constantly frequent. After she had suffered for many months from these complaints, they subsided entirely without any ob- vious cause. She then became affected with violent parox- ysms of pain in the abdomen, dysuria, and vomiting. The pain was principally in the right side of the abdomen, which was swelled, tense, and painful upon pressure; the paroxysms were succeeded by copious discharges of purifortn fluid from the vagina; and there was a temporary alleviation of the pain after every discharge of this fluid. The last time I saw her, which was a few weeks before her death, there was a gene- ral swelling and hardness occupying the whole right side of the abdomen, extremely tender to the touch, and conveying the impression of extensive organic disease. I did not see her in the fatal attack, which was in the head; it began with severe headach, impatience of light, and fever; these were succeeded by convulsion, and this by coma; and she died co- matose about a week after the commencement of this attack. Inspection.—I was present at the examination of the body, and found the surface of the brain in many places of a dark red colour. This appearance extended in some places to the depth of an inch into the substance of the brain, as was principally observed in the upper and anterior parts of both hemispheres, and on the posterior part of the left hemisphere. The parts so affected were rather softer than the other parts of the brain, and appeared to be more vascu- lar, for drops of blood exuded from them when they were cut. The internal parts of the brain were healthy, and there was no serous effusion. The longitudinal sinus near its pos- terior part was thickened in its coats, so as considerably to diminish its area. The hardness of the abdomen, which was so remarkable a short time before her death, had dis- appeared; and not a vestige of disease could be detected in any of the viscera of the thorax, abdomen, or pelvis. Case XXIV.—A lady, aged 40, had been for some time FATAL IN THE INFLAMMATORY STAGE. 93 affected with irregularity of the menstrual discharge, such as she supposed to be a prelude to its cessation. But for some days previous to the attack to be now described, the discharge had been present, and very copious, so that she felt weakened by it. This continued on the 26th October, 1825; and, in the evening of that day, on rising suddenly from her chair, she fell down on the floor in a state of syn- cope, but soon recovered, and felt no farther inconveni- ence. She passed rather a restless night, but without any particular symptom, except that early in the morning, she complained of slight uneasiness in the back of her head. Soon after this, she was sitting up in bed taking her break- fast with appetite, when, without any warning, she fell backwards in a state of the most violent general convulsion, with every character of perfect epilepsy. The convulsion soon subsided, leaving her in a state of coma; after a short time, the fit returned, and from 9 in the morning to 4 in the afternoon, she had about fifteen attacks of most severe and general convulsion, without ever recovering her senses in any degree betwixt the attacks. During all this time, she was incapable of swallowing; the eye was insensible, and the pupil rather contracted; the face pale and sallow. The pulse varied exceedingly, being sometimes of good strength, and little increased in frequency; at other times especially after the convulsion, it was frequent and feeble. General and topical blood-letting were employed with cold applications to the head, &c; and at 4 P. M. the convulsions ceased, leaving her in a state of coma, the pulse rather weak. The coma continued during the night, but in the morning of the 28th, she revived a little, began to swallow liquids, and seemed to take some notice of those about her. During the day, she generally lay with her eyes open, and at times appeared to follow objects with them, but showed little appearance of sensibility, except that once or twice she named her sister; pulse nearly of the natural standard, 13 94 INFLAMMATION OF THE HEMISPHERES. and rather weak. She took laxative medicine, by the ope- ration of which she seemed to be relieved, but recovered no farther intelligence. In the night the convulsions returned in a slighter degree than formerly, but were very frequent, sometimes occurring every 15 minutes. (29th) She was in a state of coma, with appearance of ex- haustion, incapable of swallowing, eye insensible, pupil na- tural, pulse feeble and of natural frequency; after mid-day, she recovered the power of swallowing, but soon lost it again. In the evening, the convulsions returned, with ra- pid failure of strength, and she died in the night. No pa- ralytic symptom had been observed, and the convulsions seemed to affect equally the whole body. Inspection.—A small quantity of fluid escaped in opening the dura mater. On the upper surface of the brain, there was a slight appearance of ecchymosis, forming three small patches. On cutting into the left hemisphere, there was found in the upper part of it a round defined portion of the cerebral substance of a dark red colour; it was about the size of a walnut, distinctly circumscribed, and surrounded by healthy cerebral substance. In its structure, it did not differ in firm- ness from the other parts of the brain; when cut across, it presented internally the appearance of innumerable small red points, interspersed with yellow points, but the red the most abundant. It was situated above the level of the ventricle, about the centre of the hemisphere; and, in the very same si- tuation in the right hemisphere, there was another diseased part exactly similar, except that it was a little softened in the centre. The brain in other respects was healthy, and there was no effusion in the ventricles. The arachnoid of the base was remarkably vascular on the right side; the cerebellum was healthy. In the centre of the medulla oblongata, there was a small dark portion, as if produced by a drop or two of extravasated blood. This remarkable case I saw along with Dr. George Wood. CHRONIC FORM. 95 § II.—THE AFFECTION IN A CHRONIC FORM. Case XXV.—A young lady, aged 22, was taken ill on the 20th of February, 1817. For the first week, her complaint had the appearance of continued fever; in the second week, the pulse came down, and the tongue became clean and moist, while the headach continued severe, with a sense of weight, much throbbing in the head, a look of great oppression, and occasional vomiting. Blood-letting, purgatives, blistering, and the application of cold, afforded partial relief; but, on the 5th of March, the pain returned with great severity, accompanied by violent throbbing, and a degree of squinting. The same remedies again procured an interval of partial relief; the pain was not removed, but it was less severe than in the violent pa- roxysms; there was constant throbbing in the head, and a look of much oppression; the pulse varying from 84 to 90. On the 11th, there was a violent paroxysm of headach, followed by convulsion; she was again relieved by bleeding, but on the 15th, she had loss of recollection, much confusion of thought, difficulty of articulation, and numbness of the right arm and right side of the face,—most remarkable in the latter, which had no feeling when it was touched. These symptoms dis- appeared on the following day, but the pain continued to re- cur in paroxysms; and, about the 24th, had assumed so much of a periodical character, that by the advice of an eminent physician, she was treated with arsenic, which remedy, having occasioned nausea, was given up after a week. She then con- tinued for a fortnight or more, in nearly the same state, con- stantly confined to bed, and affected with frequent returns of the pain, but without any violent attack, until the 20th of April, when it returned with great violence, accompanied by vomiting, pain in the abdomen, and double vision during the paroxysm; the pulse was at this time natural. From the be- ginning of May, the complaint began to diminish in violence; 96 INFLAMMATION OF THE HEMISPHERES. on the 20th, she was first able to be out of bed, and from that lime recovered gradually. Soon after her recovery, a large glandular swelling appeared upon her neck, which continued stationary for many months. During the summer and the following winter, she enjoyed tolerable health, but continued liable to headach, and throbbing in the head, and required the most cautious regimen. In spring, 1818, she had severe pec- toral complaints, on recovering from which, she began again to complain of headach, with sense of weight in the head, and occasional giddiness. In the beginning of June, she had se- veral attacks which resembled syncope, except that the pulse continued of good strength.; and, soon after this, she began to be occasionally forgetful, and slightly incoherent These symptoms were followed by a tendency to stupor, which was relieved for a time by purgatives, and repeated blistering; at this time, her pulse was generally from 96 to 100, and her countenance was pale and exhausted. As these symptoms advanced, her pectoral complaints disappeared, and, after va- rious turns of the symptoms in the head, she was found speech- less in the morning of the 3d of July. She lay with her eyes open, and appeared to take notice of objects; pulse from 90 to 100, and weak, face pale. She continued in the same state on the 4th; on the 5th, there was increase of coma, with loss of the power of swallowing, and paralysis of the right side. (6th) Recovered the power of swallowing; pulse 130; ex- pression of the countenance intelUgent; eye natural; but she made no attempt to speak. (7th) In the same state; took flowers in her left hand, and appeared to be amused by them; right side paralytic; great obstinacy of the bowels. (9th) More oppressed. (10th) Perfect coma; pulse 130. She died in the evening. Inspection.—The dura mater adhered intimately to the left hemisphere of the brain, at a spot the size of a half-crown piece, about the middle of the hemisphere near the falx. At CHRONIC FORM. 97 this place, a portion of the brain, the size of a large walnut, was externally of a deep red colour, and this redness appeared both on the upper surface, where the membranes adhered to it, and on the inner surface, where it was in contact with the falx. When cut into, this portion appeared rather firmer than the healthy cerebral substance, except towards the centre, where it was soft, as if approaching to suppuration. The external circumference of the portion retained the deep red colour, to the depth of about half an inch; the central parts were of an ash colour, with interspersed portions of a dark reddish brown. On the upper surface, where the membranes adhered to it, there was a deposition of false membrane to the extent of the adhesion, and the dura mater, at the place of the adhesion, was thickened and spongy; the coats of the longitudinal sinus also appeared to be thickened, at the place where it came in contact with the diseased portion of the brain. There w^as no effusion in the ventricles, and no other disease in any part of the brain. The lungs were extensively tubercular, and the pleura lining the diaphragm, on the left side, was rough and irregular, from numerous small firm ex- crescences on its surface, resembling warts. Case XXVI.—A lady, aged 60, for whose case I am in- debted to Dr. Hay, in the end of September, 1824, suffered an apoplectic attack with partial paralysis of the right side. She was relieved by bleeding, and appeared to be recovering favourably, until the 8th of October, when she had another attack. She did not then become insensible, but complained of a strong pulsation over the body, particularly on the right side, the arm and leg of which were again considerably para- lysed. From this time, she gradually lost the power of these parts, first of the leg and then of the arm; she had occasional returns of the feeling of pulsation, and frequently applied her hand to the right side of her head, in which she said she felt uneasiness, and to which it was observed that, during sleep, 98 INFLAMMATION OF THE HEMISPHERES. her hand was frequently carried; the bowels were exceeding- ly torpid. The usual treatment was employed by Dr. Hay, in the most judicious manner, without relief; her strength gradually declined, and she died on the 26th of December, having fallen into a comatose state, with loss of the power of swallowing, about a week before her death. Inspection.—The dura mater was found to adhere very firmly to the brain, at a spot about the centre of the left he- misphere, on the upper part. The substance of the brain be- neath this portion seemed firmer than natural, and, when cut into, was of a bright red colour. This portion was about an, inch and a-half in extent downwards, and of nearly the same breadth; and the cerebral substance surrounding it appeared more vascular than the other parts of the brain. Deeper in the substance of the brain, a similar portion was met with, the size of a hazel nut, which was of a deeper red colour than the former. The corpus striatum of the same side was of a red colour, inclining to purple, soft in its texture, and presenting, when cut across, numerous points of vessels. The right he- misphere was healthy; there was a small quantity of fluid in the lateral ventricles; and, in both ventricles, the choroid plexus was turgid with blood, and contained in its substance numerous small cysts of a bluish colour. The vessels on the surface of the left hemisphere, and betwixt the convolutions, were very turgid with blood; and, in some of the deeper con- volutions, there was a slight appearance of ecchymosis. § III.—The inflamed mass passing into ramollisse- ment. Case XXVII.—A girl, aged 7, had been falling off for about two months before her death, having some cough, with considerable emaciation; but her appetite was good. On the 22d of July, 1826, she had pain in the bowels, with diar- rhoea, and some vomiting. These symptoms wrere relieved CHRONIC FORM. ' 99 by the usual remedies, but she still complained of pain in her bowels, and had some cough. Three or four days after this, she complained of headach, and her speech was sensi- bly impaired; about this time, also, she complained of pain in the right ear. Some peculiarity of speech had been ob- served before on one or two occasions, when she was able to go about. On the 27th, she was first seen by Dr. Beil- by, who found her affected with headach, and pain of the ear; with considerable embarrassment of speech, and a small frequent pulse. On the two following days, she was con- siderably relieved in regard to pain, and the symptoms as- sumed more the character of continued fever. I saw her on the 30th, when there was considerable coma, so that she could scarcely be made to answer a question; pulse 90; the pupil much dilated, and there had been considerable return of headach. On the 31st, she was speechless, with nearly perfect coma; pulse 80. She continued in the same state on the 1st of August, with the pulse becoming frequent. On the 2d, she began to be affected with paroxysms of con- vulsion, which attacked only the right side of the body. The limbs of the left side appeared to be paralytic, or at least were never observed to move, even during the con- vulsions of the right side. These paroxysms continued to recur for four or five days; she then sunk into a state of per- fect coma, and died on the 10th. She had retained the pow- er of swallowing liquids when they were put into her mouth, and seemed to recover a slight degree of motion of the left arm. « Inspection.—On removing the dura mater, several patches of false membrane were found on the outer side of the right hemisphere; chiefly at the openings of the convo- lutions, and dipping down considerably betwixt them. On cutting through this hemisphere, a defined portion was met with in a state of recent inflammation, presenting a uniform red colour, and a natural consistence. It was about 24 inches 100 INFLAMMATION OF THE HEMISPHERES. in length, extending from before backwards, about an inch in breadth, and as much in thickness. At its anterior part, it was connected with another portion, about an inch in ex- tent in all its dimensions, in a state of perfect ramollissement, and of a yellowish white or ash colour; and the two struc- tures evidently passed into each other, the inflamed portion becoming gradually softer as it approached the softened part. Along the whole of that part of the hemisphere, through which the inflamed mass extended, all the convolutions were firmly glued together through their whole extent, by a deposition of very firm adventitious membrane; and there was a similar adhesion of the anterior to the middle lobe. There was slight effusion in the ventricles, but the central parts were healthy. In various parts of the brain very mi- nute tubercles were observed; and, on the base of the brain at the junction of the left crus cerebri with the tuber annu- lare, there was an irregular, tubercular mass of considera- ble extent, mixed with adventitious membrane. In the lungs there were numerous minute tubercles, all in a solid state. In the mucous membrane of the intestines, especially at the lower extremity of the ileum, there were observed numerous minute black spots, each of which, when viewed by a lens, appeared to be surrounded by a minute circle of inflammation. Case XXVIII.—A lady, aged 24, had long been liable to severe attacks of headach, which occurred at irregular inter- vals, and were excited by various causes, such as warm rooms, and bodily exertions, and for which she had used a variety of treatment with little benefit. They had not, however, affect- ed her general health, and she was recovering favourably from her second accouchement, under the care of Dr. Mac- kintosh, when, about the beginning of the second week, she was seized with severe headach, and considerable oppression. She was bled with relief, and continued tolerably well for se- PASSING INTO RAMOLLISSEMENT. 101 veral days, though with occasional complaint of headach. On Sunday, 14th January 1827, after a disturbed night, with some delirium, she complained in the course of the day of slight uneasiness in her head, and a peculiar feeling of numbness in the back of the head and neck; but she was otherwise well, and in good spirits, till about ten o'clock at night, when she suddenly complained of numbness and loss of power of the right hand. These feelings spread rapidly along the arm, which very soon became entirely paralytic, and this was speedi- ly followed by loss of speech, and twisting of the mouth. She was immediately bled, and when I saw her soon after the bleed- ing, I found her with a look of intelligence, but without any attempt at speech; the pulse quick and feeble, the right arm entirely powerless, and with a degree of spasmodic rigidity. A few hours after, the right leg became also paralytic. She continued without any farther change till about three o'clock in the morning, when she was seized with severe and general convulsion, affecting both sides of the body, but strongest on the left side. The convulsion returned three times betwixt this and mid-day of the 15th, after which the attacks became much more frequent; and from this time she showed no ap- pearance of sensibility. She had from the first swallowed with difficulty, but every attempt to make her swallow now excited general convulsion. During the attacks, the face was much distorted, and equally so on both sides; the limbs of the left side were violently convulsed, while the right arm was affected chiefly with a rigid spasmodic contraction, and a tre- mulous motion. The convulsions now returned with great violence and frequency, sometimes every half hour, and each attack continued for ten or fifteen minutes. The pulse was generally rapid; sometimes extremely feeble, and sometimes of tolerable strength. The breathing was sometimes frequent and convulsive, and sometimes slow and oppressed, as if she were moribund; and on many occasions she was considered as being within a few minutes of death; but she continued to 14 102 INFLAMMATION OF THE HEMISPHERES. live in this state till the evening of the 16th, being forty-eight hours from the attack. On the second day, the rigid contrac- tion of the right arm had disappeared, and it continued en- tirely paralytic, except when it was affected by the convul- sion. Inspection.—On the upper surface of the left hemisphere, and between the convolutions, there was a considerable ecchy- mosis, produced by a very thin layer of extravasated blood betwixt the arachnoid and pia mater. The veins on the up- per part of this hemisphere were remarkably turgid, and were found to be distended with dark blood in a perfectly firm fleshy state, mixed with some firm white matter; and their coats appeared to be thickened. Where these veins entered the longitudinal sinus, there was a remarkable diminution of its area, arising partly from the thickening of its coats, and partly from deposition of firm white matter on its inner sur- face. In the substance of the left hemisphere, about the cen- tre of its long diameter, towards the outer side, and rather above the level of the ventricle, there was a distinctly defined portion, about the size of a small walnut, in a state of complete ramollissement, but retaining entirely the natu- ral white colour; and immediately bordering upon the part, there was a considerable portion in a state of the deep red- ness described in the former cases; the brain in other re- spects was healthy, except a small softened spot in the right hemisphere. This important case was also seen by Dr. Kellie and Dr. Scott. § IV.—Extensive ramollissement of the corpus STRIATUM. Case XXIX.—A man aged 25, about four years before his death was first affected with difficult breathing, strong ac- CHRONIC, WITH RAMOLLISSEMENT, &C. 103 tion of the heart, dropsical symptoms, and irregular pulse; af- ter some time he was considerably relieved, but about a year and a half after this he again became dropsical, and about this time was suddenly seized with palsy of the left side of the body, delirium and coma. The coma subsided in a few days, and he recovered the use of his limbs in a few weeks, so that he was able to return to his work as a joiner. The symp- toms in his chest, however, soon obliged him to give it up, the strong action of the heart continuing, with small irregular pulse, and much dyspnoea. In May, 1S21, he was again at- tacked with palsy of the left side, accompanied by coma and delirium, and recovered in a few weeks. In these two at- tacks of palsy, there never had been any complaint of head- ach; but in March, 1823, he was attacked with severe head- ach, followed by loss of memory, palsy of the left side, and coma. He again recovered in a few weeks, so as to be able to walk about; the symptoms in the thorax continued as be- fore. 20th October, 1823, he was a fourth time attacked with palsy of the left side, accompanied by violent pain re- ferred to a particular spot on the coronal suture, a little to the right side. This was followed by maniacal delirium, the pulse feeble and irregular, the mouth twisted, and the left eye distorted. After some time he recovered considerably, so as to be able to walk with a little assistance, dragging his leg, but continued to be occasionally delirious till a few days be- fore his death, when the palsy again became complete, with much delirium, and some convulsive affections, but no coma. He died on the 17th December. Inspection.—There was nothing unusual on the surface of the brain, and no effusion in the ventricles. The right cor- pus striatum was externally of a peculiar dull yellow colour, and when cut into was found to be throughout its whole sub- stance in the extreme state of ramollissement, extending to a great depth; it was mixed with a slight appearance of pus, and the soft undulating mass was separated from the ventricle 104 INFLAMMATION OF THE HEMISPHERES. by a delicate membrane. There was also ramollissement, but of small extent in the left corpus striatum. The heart was generally and considerably enlarged, the right ventricle thickened; the left ventricle enlarged, without thickening; the left auricle much enlarged, and containing a large organized polypus firmly attached to its sides, and deposited in succes- sive layers like the deposition in the sac of an aneurism. § V.—The affection in a chronic form, with ramol- lissement OF SMALL EXTENT, AND REMARKABLE SYMP- TOMS. Case XXX.—A gentleman, aged 26, of a plethoric habit, had suffered occasionally for two or three years from head- ach and vertigo, which were always relieved by depletion. On 12thx\pril, 1827, while walking out, he was seized with confusion and giddiness, embarrased speech, and a consi- derable degree of paralysis of the right leg. He was ra- ther pale; his pulse was 70, and soft; and he did not com- plain of any headach. The usual treatment was adopted with activity by Dr. Combe of Leith, without much relief. On the contrary, after several days he began to complain of acute headach, accompanied by vomiting and hiccup; and the other symptoms continued nearly as before,—his speech being laboured and slow, and his memory very defective. After some weeks those symptoms subsided, so that he was able to walk out; but the headach continued with frequent vomiting. The pain was chiefly referred to the left side of the head, sometimes to the occiput, and there was occa- sional numbness of the right arm. When I saw him, along with Dr. Combe and Dr. Kellie in July, his chief complaint was of frequent and irregular attacks of vo- miting, occurring daily, or repeatedly during the day. It came on very suddenly, without previous nausea, and CHRONIC, WITH RAMOLLISSEMENT, &C. 105 he was often awakened in the night by the sudden attack of vomiting. He had now a pale sickly look; there was no paralytic affection, and little complaint of headach; though he still had occasional uneasiness in the head, sometimes referred to one part of it and sometimes to ano- ther. When he did refer it to a particular part as the prin- cipal seat of the pain, it was either the left temple or the occiput. But the headach at this time was slight and tran- sient, and the symptoms in the stomach were so much the more prominent, that it was a matter of much doubt whe- ther there was now any fixed disease in the head. The vomiting was much relieved by the oxyd of bismuth, so that he was free from it for several days. But it soon returned and went on as before, with increasing debility, great list- lessness, and bad appetite; pulse little affected. He had now a peculiar unsteadiness of his limbs, so that on first getting up into a standing posture, he staggered very much, and required some time and attention to steady himself. When he had accomplished this he walked with tolerable firmness. The symptoms went on in this manner till the 27th of October, when he was suddenly seized with violent and continued convulsion, and died in nine hours. Inspection.—In the substance of the middle lobe of the left hemisphere of the brain, about the level of the lateral ventricle, there was a portion in a state of complete ramol- lissement, about an inch and a half in length, and an inch in its other dimensions, and the neighbouring parts appear- ed unusually vascular. The tuber annulare and Pons Varo- lii were softer than usual, but otherwise healthy. No other morbid appearance could be discovered in the head, and all the other viscera were healthy. It is unnecessary to point out the very remarkable features of this case. The sudden attack so closely resembling the or- dinary paralytic attack, must have been connected with the commencement of the inflammatory stage. The remarka- 106 inflammation of the hemispheres. ble symptoms in the stomach in the farther progress of the disease, and the mode of its termination, make it altogether a case of great value in the pathology of this remarkable af- fection. The following case shows the same morbid ap- pearance, with a train of symptoms considerably different, but with a remarkable similarity in the mode of its termi- nation. Case XXXI.—A gentleman, aged 38, during two years be- fore his death had suffered several epileptic attacks, from which, however, he had always speedily recovered. On the morning of 27th December, 1827, he was found in bed speech- less and paralytic on the right side. He recovered his speech in the course of the day; the palsy continued in the usual man- ner, and after some time he began to recover a degree of mo- tion of the parts. When he came to Edinburgh, about a month after the attack, he had recovered the use of his leg so far as to be able to walk once or twice across his room with much exertion; his arm was improved in a much less degree: his speech was distinct, but his mouth was considerably dis- torted, and his mind was somewhat impaired. He now con- sulted Dr. Thomson, and under the usual treatment he was progressively improving, so that at the end of another month he could walk along the streets to a considerable distance, though with a dragging motion of his leg, and could nearly raise his arm to his head. In the evening of 22d February he went to a supper party, and seemed remarkably well; but departed considerably from the abstemious regimen to which he had been previously restricted. About 8 o'clock on the morning of the 23d he was found in bed in a state of complete insensibility, accompanied by severe and general convulsion, which was strongest in the limbs of the right side. The face was much convulsed, the eyes rolling and insensible, the res- piration laborious and convulsive. Blood-letting and the other usual means were actively employed without any relief. The chronic, with ramollissement, &c. 107. convulsion continued unabated in the state now described, when I saw him at eleven, and he died at two. Inspection.—The brain externally was healthy, except some old adhesion of the membranes near the posterior part of the falx, and very trifling effusion under the arachnoid. The ventricles contained the usual very small quantity of fluid. On the outer side of the left ventricle, and sepa- rated from it by a thin partition of healthy cerebral sub- stance, there was a defined portion in a state of complete and diffluent ramollissement. The portion thus affected was about an inch in depth; about half or 3-4ths of an inch in diameter at the upper part, and became gradually narrower as it descended by the side of the ventricle, until it terminated almost in a* point. There was considerable softening of part of the medulla oblongata, and the upper part of the spinal cord. No other vestige of disease could be discovered on the most careful examination. I do not attempt to offer any explanation of the symp- toms in these two most remarkable cases, or to reconcile them with the old notions in regard to diseases of the brain. I give them as facts carefully ascertained, and faithfully related, to be illustrated by farther observations on this very remarkable disease. § VI.—The affection in a chronic form, with ex- tensive ramollissement, and remarkable disease OF the basilar artery. Case XXXII.—A young man, aged 18, had been for six or eight weeks affected with cough and pain of the chest, and was supposed to be phthisical; but for several days he had been much better, when on the 15th December, 1819, he suddenly fell down deprived of sense and motion, and paralytic on the left side, with twisting of the mouth. When partially recovered, he complained of severe pain in 10S inflammation of the hemispheres, the right temple; his speech was very indistinct; counte- nance expressive of great stupor. The usual treatment was actively employed, but without much benefit, and he continued for about ten days with little or no improvement; the left side perfectly paralytic; a great degree of coma; the speech very indistinct; but he still pointed to the right tem- ple as the seat of fixed uneasiness. During this time his pectoral complaints had disappeared. In January, 1S20, he began to improve, so as to have less uneasiness in his head, and considerable motion of the leg, but the arm continued entirely paralytic. His cough now returned, with consi- ■derable pain in the right side of the chest. He continued without farther change till the 15th of February, when he complained of pain in the back of his head, and was seized with loss of speech, and of the power of swallowing. He soon recovered his speech, but the power of swallowing was permanently lost, so that from this time he was con- stantly fed by liquids introduced into the stomach through an elastic gum tube. He was now quite distinct, and did not complain of any pain; the cough again abated; pulse of natural frequency but feeble. In the beginning of March he seemed to improve a little in strength, so that he was several times taken out in a carriage; there was considera- ble motion of the left leg, but the arm continued perfectly paralytic; no return of the power of swallowing; speech and intellect entire. He died rather suddenly on the 20th of March, having the day before become extremely weak and pale without any obvious cause. Inspection.—On removing the dura mater, there ap- peared on the middle of the right hemisphere a remarkable depression, which, when cut into, was found to arise from an extensive mass of pure ramollissement; the part being in the state of a soft white pulp, without any appearance of pus, and without fetor; it extended the whole depth of the hemisphere. In,the cerebral matter adjoining to this dis- with ramollissement and suppuration. 109 ease, there was a small abscess, no larger than a bean, lined with a firm soft cyst of coagulable lymph. There was very little effusion in the ventricles, and no other disease in the substance of the brain. On raising the brain, a remarkable appearance was found in the basilar artery; through the extent of about an inch it was very much enlarged and hard, and this portion was found to be completely filled up by a firm white matter without any appearance of blood. Anterior to this portion, there was a small coagulum of blood in the artery. The lungs were tolerably healthy, but there was a considerable deposition of coagulable lymph, forming a thick firm mass betwixt the right lung and the pleura costalis at the lower part immediately above the diaphragm. § VII.—Ramollissement combined with suppuration. Case XXXIII.—A man, aged 24, had been liable for two years to headach, which was always referred to the right side of the head. In February, 1818, he contracted syphilis, which, being neglected, became inveterate, and continued fourteen months. During this time the headach became more severe, and was always referred to the right temple. In June, 1819, he was affected with numbness of the left thumb, which gra- dually extended over the arm, and he had afterwards com- plete paralysis of the left arm and leg, with severe pain in the right temple. This was followed by maniacal delirium, which continued for three days. He was relieved by copious bleed- ing, &c. and was completely recovered within a month. In August, he was affected in the same manner, and again en- tirely recovered. He continued well till 27th November, when he complained of violent pain over the whole head, and in the night was observed to have lost his speech and the power of the left side; the jaws were locked; he appeared 15 110 inflammation of the hemispheres, sensible, and expressed his feelings by signs; pulse 98, small and irregular. There was no change on the 28th; on the 29th, the body was rigid as if tetanic; he then became comatose, and died in the evening. Inspection.—The anterior and lower part of the right he- misphere was extensively diseased, forming a mass in which softened cerebral matter was mixed with pus of intolerable fetor. There was very little fluid in the ventricles, and no other disease could be detected in any part of the brain. § VIII.—Undefined suppuration. Case XXXIV.—A gentleman, aged 18, had been for many years affected with a considerable degree of deafness, and had been liable to suppuration of the ears. In 1810 he was af- fected with a chronic abscess behind the left ear, by which a probe could be passed to a great depth into the cells of the mastoid process. This sore discharged more than a year, and then healed, leaving a deep cicatrix. From this time he was liable to headach, which became more severe in the beginning of the year 1813. May 14, 1813, after having been for some days languid, and complaining a little of his head, he was seized with se- vere headach and frequent vomiting. He was much oppressed and lay in a dozing state, impatient of being disturbed; pulse 60. He was treated in the usual manner, by free, general, and topical bleeding, purgatives, blistering, &c. On the 15th the headach was still violent, but the vomiting had abated; pulse 60; had several severe attacks of shivering, was op- pressed and disposed to sleep, but sensible; eyes natural. (16th,) Headach relieved; increasing oppression. From this time he lay in a state of partial stupor, with much talking, which was generally coherent; pulse varying from 80 to 120. He died on the 22d, rather unexpectedly, and without perfect with undefined suppuration. Ill coma. He had continued to know the persons about him till about twelve hours before his death. His sight continued natural except on the day of his death, when he appeared to be blind; no paralytic affection, and no convulsive symptom had been observed. Inspection.—The right hemisphere of the brain, to about half its depth, was entirely reduced to a mass of fetid pus: in the centre, it was fluid, and towards the external parts, it was more of a pulpy consistence. In this mass, there were found some small coagula of blood, and the ventricles contained a considerable quantity of bloody fluid. Case XXXV.—A gentleman, aged 18, (10th July, 1815,) was affected with violent headach, extending along the upper and back parts of the head, and accompanied by severe pain in the neck, where it was much increased by the motion of the head. There was much oppression; pulse natural; face rather pale; tongue clean; eyes natural. He had been ill three days, and the complaint had commenced with shivering; he had been many years affected with deafness, and liable to sup- puration of the ears. The usual practice was employed; ge- neral and topical blood-letting, purgatives, blistering, &c. The bleeding gave great relief at each repetition of it, and the blood was sizy; but the relief was transient. On the 13th, he had squinting and double vision, which continued on the 14th, but then went off and did not return. The headach continued with many variations in degree; sometimes he made little complaint, and at other times, was in violent pain; there was sometimes a degree of delirium, but it was slight and tran- sient; there was much oppression, but no coma, and no para- lysis. He died on the 17th rather suddenly. At my last visit, he had raised himself in bed with little assistance, answered questions distinctly, and knew every person about him; pulse 60; sight natural. His death occurred a few minutes after I had left the house. 112 inflammation of the hemispheres, Inspection.—The whole of the posterior part of the left hemisphere of the brain was one mass of undefined suppura- tion. There was considerable deposition of coagulable lymph on the surface of the brain in several places, especially under the anterior lobes. There was a very small quantity of fluid in the ventricles, and considerable ramollissement of the for- nix. In the substance of the brain, near the base, there was a small tumour of an ash colour, which contained a cheesy matter approaching to suppuration. A portion of the dura mater covering the temporal bone behind the auditory por- tion was thickened and spongy, and there was slight appear- ance of caries in the portion of bone with which the diseased membrane was connected. § IX.—Extensive undefined suppuration with extra- VASATED BLOOD. Case XXXVI.—A man, aged 40, had complained for two months of frequent pain and throbbing in the left side of his head. In March, 1814, he began to be affected with convul- sive motions in the right arm and leg, which attacked him in paroxysms, and usually continued about a minute, leaving him in the intervals able for his usual employment as a blacksmith. After blood-letting and purging, these paroxysms became less frequent, and after eight or ten days ceased. He was then af- fected with giddiness and confusion of thought, and conside- rable torpor of the right side. After some time, this was at- tended with motions, in the right arm and leg, exactly re- sembling those of chorea. The muscular power of these parts wras at the same time diminished, and, at the end of two months from the first appearance of the spasmodic affections, the arm and leg became entirely paralytic. His speech was then affected, being first inarticulate, and afterwards gradually lost, so that after the middle of June he never was able to arti- WITH ENCYSTED ABSCESS. 113 culate a word. His pulse, which till this time had continued quite natural, now became a little frequent; he passed his urine and feces involuntarily, but his mental faculties seemed to be entire. He took food when it was offered him, and put out his tongue whe# he was desired; his eye was natural, and the ex- pression of his countenance intelligent. His sight and hearing appeared to be perfect, but he never attempted to speak. He often screamed as if from pain, at the same time laying his hand on his forehead, and frequently shed tears. He con- tinued in this state till the end of July, when he became co- matose, and died in three days. Inspection.—On removing the dura mater, the left hemi- sphere of the brain felt soft and fluctuating through its whole extent like a bag of fluid; on cutting into it, there was about half an inch in thickness of sound cerebral substance, the re- mainder of the hemisphere was found nearly reduced to a fluid mass, partly consisting of purulent matter, and partly of cere- bral substance, in a soft pulpy state; but the greater part was purulent. From this mass of disease, the ventricle was sepa- rated merely by the membrane which lines it, and contained a small quantity of serous fluid. In the substance of the left thalamus, there was a coagulum of blood, of the size of a walnut, § X.—The encysted abscess. Case XXXVII.—A girl, aged 11, thin and delicate, after having complained for some days of headach, was seized on the 11th of January, 1817, with convulsion, which continued about half an hour. I saw her on the 12th, and found her affected with severe headach, and paralysis of the right arm, which had taken place immediately after the convulsion. The pulse was 100; the tongue foul; the face rather pale, and the eyes languid. Being bled from the arm and purged, and cold being applied to the head, she was much relieved. On the 114. INFLAMMATION OF THE HEMISPHERES, 13th, the pulse was natural, the headach was much abated, and she had recovered considerable motion of the arm. On the 15th, the headach being increased, and the arm more pa- ralytic, she was bled again; and on the 16th and 17th, she was much relieved, the pulse natural, and the motion of the arm much improved. On the 18th, after being affected with increase of headach, and some vomiting, she became convulsed, the convulsion being confined entirely to the head and the right arm. The head was drawn towards the right side with a rolling motion of the eyes, the arm was in constant and vio- lent motion; she was sensible, and complained of headach; pulse 100. Being bled to Jviii. the convulsion ceased in- stantly, and the headach was relieved, but the right arm con- tinued in a state of complete paralysis. (19th and 20th,) The arm had recovered a little motion,- some headach con- tinued, with occasional vomiting; pulse 60. On the three following days, the convulsive attacks returned several times; they did not now affect the head or face, but were entirely confined to the right arm, which, after the 23d, was left in a state of permanent paralysis. Hitherto no other part of the body had been affected by the convulsion; but on the 24th, it attacked the right thigh and leg, and left them in a state of paralysis; pulse 60. The former remedies were again em- ployed with activity, without any effect in arresting the pro- gress of the disease. The thigh and leg now went through a course precisely similar to that described in regard to the arm, and on the 29th, remained in a state of permanent paralysis. When the convulsion first began to affect the leg, the arm was affected at the same time; but afterwards it was confined to the thigh and leg, the arm remaining motionless. February 4th.—Complete paralysis of the whole right side; no return of convulsion; she continued quite sensible, and made little complaint; pulse from 50 to 60. She now con- tinued for several days without any change, and except the WITH ENCYSTED ABSCESS. 115 palsy of the right side, every function was natural. She was quite sensible, appetite good, pulse and vision natural, and she made little complaint of any uneasiness. She was, however, inclined to lie without being disturbed, and gradually became more oppressed. On the 11th, this had increased to perfect coma, in which she continued for three days, and died on the 14th. Inspection.—In the upper part of the left hemisphere of the brain, there were two distinct defined abscesses, contain- ing together from six to eight ounces of very fetid pus. They were lined by a firm white membrane, and a thin septum of firm white matter separated them from each other; the one was in the anterior part of the hemisphere, very near the sur- face, and the other immediately behind it; they had no com- munication with each other, or with the ventricle. In the posterior part of the right hemisphere, there was a small ab- scess containing about half an ounce of pus. There was no serous effusion in any part of the brain, and no other morbid appearance. Case XXXVIII.—A gentleman, aged 21, had been for many years affected with cough and puriform expectoration, which was often in considerable quantity; he had also repeat- ed attacks of haemoptysis, some of them copious. He was stinted in his growth, and of a feeble habit, but in other re- spects enjoyed tolerable good health, and was able to attend to his business as clerk to a solicitor, till the beginning of July, 1822, when he began to complain of headach. For some time before this he had observed occasionally, while sitting at his desk, a deficiency of sight, but had taken little notice of it. This illness began with headach, loaded tongue, and quick pulse, and so continued for eight or ten days without exciting any alarm. He was treated in the most judicious manner by Mr. Johnston, and seemed to be recovering gradually, the 116 INFLAMMATION OF THE HEMISPHERES, pulse coming down, and the headach being considerably re- lieved, though not quite gone. I saw him about the 15th. The pulse had then fallen to 50, he was feeble and languid, with some headach, and a look of oppression. The pupil was rather dilated; there was an evident imperfection of vi- sion, and about this time there was first observed a weakness of the left arm and leg. The headach had been at first re- ferred chiefly to the left side of the head, but now it was principally on the right side, though he often described it as extending across the forehead. The cough continued, with considerable expectoration of a tenacious puriform fluid. There was no pain in the chest, and no uneasiness in breath- ing, but the pulsation of the heart was felt entirely in the right side of the thorax. This peculiarity had been observed for several years, but it could not be ascertained at what period it had commenced. His pulse was now feeble and languid, and his general ap- pearance pale and exhausted. For several days there wag little change, the pulse continuing about 50, sometimes 48. After three or four days there was a slight convulsive attack, and a second about two days after; these, however, made no change in the symptoms. About the 24th there was some incoherence, but it was slight, and soon went off. The pupil was still considerably dilated, though sensible to the light; a degree of headach continued, but it was not much complained of. He was now disposed to lie without being disturbed, but when spoken to was quite intelligent. About the 26th, there was a remarkable improvement in his appearance, and much less headach, the pulse beginning to rise. (27th) Pulse 108; more comatose, but sensible when roused. (28th) Pulse 120; had copious purulent expectoration in the morning, and seemed much exhausted. He lay much oppressed, but when roused answered questions distinctly. He could still move the left arm, but slowly and with difficulty, and with an awkward motion, somewhat resembling that of chorea, or as if he threw WITH ENCYSTED ABSCESS. 117 the whole arm forward by a strong effort of the muscles of the shoulder; he had seldom attempted to move the leg for several days. In the course of this day there was observed a slight degree of squinting; and he died in the night without any other change. Inspection.—The brain was externally healthy. In the upper and anterior part of the right hemisphere, very near the surface, there was an abscess containing about an ounce of very fetid pus.. In the posterior part of the same hemis- phere, there was another abscess rather smaller. These ab- scesses were distinctly defined, but not very distinctly lined by a membrane, and the cerebral matter surrounding them was slightly softened. In the anterior part of the left hemis- phere, immediately under the surface, and at the very angle of it which lies Over the orbit, there was a small abscess con- taining from one to two drams of pus, and another rather larger in the posterior part of the hemisphere. These ab- scesses were all above the level of the ventricles, except the one in the posterior part of the right hemisphere, which went down a little behind the ventricle. The ventricles were emp- ty, and there was no other disease in the brain. The right lung was reduced to a small dark-coloured mass, resembling the spleen, and internally presented a series of abscesses, com- municating with each other, and with the trachea. The heart lay in contact with it on the right side of the thorax; and the left lung was so enlarged as to fill all the remainder of the ca- vity. It was quite healthy, except a small tubercular mass in a firm state, in the upper part of it. The following case shows the encysted abscess with symp- toms remarkably different from those mentioned in the pre- ceding cases. Case XXXIX.—A man, aged 43, had complained of head- ach for ten days, but had not been prevented from following 16 118 INFLAMMATION OF THE HEMISPHERES, his usual employment. At one o'clock in the morning of the 9th May, 1827, he was seized with palsy of the left side of his face, and became incoherent and unmanageable. When he was seen some hours afterwards by Dr. Huie these symp- toms continued; the pupils were contracted, and the eyes were in perpetual motion; the skin hot; the pulse 90, full and strong. There was no palsy of any of the limbs, but, on the contrary, he made the most powerful resistance when Dr. Huie attempted to bleed him, which, however, he accom- plished to the extent of thirty ounces. In the afternoon there was considerable coma with stertorous breathing, but both these symptoms disappeared after another bleeding. On the 10th, the palsy of the face was gone, but he was still incohe- rent and restless; pulse 100. Topical bleeding was employed, and purging with croton oil, &c. On the 11th, he was co- herent and quiet, pulse 108; but he became incoherent in the afternoon. On the 12th, he was sometimes drowsy and some- times restless; pulse 120 and small. He died in the night. Inspection.—Three abscesses were found in the brain, all completely encysted, and filled with well formed pus. The first was in the anterior lobe of the left hemisphere, and con- tained about three drams of pus. The second was in the posterior lobe of the same hemisphere; it was considerably larger, and had burst into the ventricle, which was filled with the matter. The third was in the posterior part of tlie right hemisphere, and appeared to be making its way towards the surface. A still greater obscurity of symptoms occurred in the following remarkable case, for which I am indebted to Dr. Alison. It occurred under his care in the Clinical Ward, in June, 1827. Case XL.—A man aged 2G, was seized with shivering, headach, sickness, and sudden loss of strength, with fits of WITH ENCYSTED ABSCESS. 119 delirium in the night. Two days after the occurrence of these symptoms, he was admitted into the Clinical Ward. At this time, he was able to walk when supported on one side, but with feebleness and difficulty, his legs, particu- larly the right, being at each step dragged along, rather than raised from the ground; his expression was dull and listless, but he said he was free from pain. A few hours after, he complained of violent pain in the occiput, with frequent vomiting. The pain was relieved by a bleeding. In the evening he was oppressed, and answered questions slowly and with difficulty; there was still some headach, with nausea; the skin hot and dry; the pulse varying from 80 to 100, sharp, and moderately" full; tongue dry; pupils natural: respiration somewhat short and hurried. About half an hour after this report was taken, he sunk into per- fect coma, with dilated pupils, for which another bleeding was employed without relief, and in less than an hour he died. Inspection.—The brain was externally of a reddish-brown colour. On the light side of the vertex, there was a spot the size of a half-crown, of a greenish yellow colour. On removing a very thin portion from this spot, an irregular abscess was opened, which contained well formed pus, and which seemed to be entirely limited to the cineritious sub- stance. In the posterior part of the left hemisphere, on a level with the corpus callosum, there was another abscess, which seemed to be seated in the medullary matter, and was surrounded by softened cerebral substance of a livid yellow colour. In the posterior part of the right hemis- phere, there were two other abscesses, one in the cortical substance, and the other in the medullary. Here also a fifth abscess was found, of a very small size, being about the size of a pea, but surrounded by a more defined cyst than any of the others; there was extensive ramollissement of the fornix, septum lucidum, and the lower part of the cor- pus callosum. The left corpus striatum was softened, and 120 ABSCESS OF THE CORPUS STRIATUM. had a greenish-yellow colour; the surface of the left thala- mus was ragged and almost fluid, but retained its natu- ral colour. § XI.—Abscess of the corpus striatum of very SMALL EXTENT. Case XLI.—A gentleman, aged 33, in January, 1817, had a severe attack of pneumonia with symptoms of cardi- tis, from which he recovered perfectly, after having been bled to the extent of 160 ounces in five days. For some time after he felt his breathing a little uneasy, but this gra- dually subsided; and he enjoyed very good health till the middle of February, 1819, when, on awakening one morn- ing he found his whole left side numb and insensible, but without any remarkable diminution of motion. The loss of feeling extended along the half of his face, the line being drawn with much precision along the centre of the nose; he had no other complaint; had no headach, and the pulse was natural. He was freely bled and purged; the symp- toms then gradually subsided, and in four or five days were gone. From this time, however, his friends remarked that he was less acute in business than formerly, and that his memory was somewhat impaired. In the month of May, this deficiency rather increased; and about this time, he complained of slight uneasiness in his head, for which he was again bled. He continued, however, to attend to his business as a solicitor, till the 16th, when he appeared considerably confused, and complained of his head; his pulse was now feeble, so as not to indicate farther general bleeding. After a purgative and topical bleeding he was much relieved, and in the evening was quite distinct and made no complaint. About two in the morning of the 17th he was heard to make a remarkable noise in his sleep, which ABSCESS OF THE MEDULLA OBLONGATA. 121 was found to be owing to a kind of convulsive breathing. This was speedily followed by perfect coma, with loss of the power of swallowing. He lay in this state till nine o'clock at night, and then died. All the usual remedies had been employed without the slightest effect. Inspection.—Every part of the brain was found in the most healthy state, till we came to the left corpus striatum; in the lower part of this there was a small irregular abscess, not exceeding the size of a small bean, containing purulent matter of remarkable fetor. In the centre of the right cor- pus striatum; there was also discovered a minute abscess regularly and nicely defined, but no larger than a small pea. No other disease could be detected in any part of the body. § XII.—Abscess of the medulla oblongata. Case XLII.—A child, aged 16 months, whom I saw only a week before his death, had been in a declining state of health for ten months. The beginning of his bad health was ascribed to a fall, in which he was supposed to have sustained an injury of the back part of the head or neck. From this time he was often much oppressed, and had been gradually wasting. Three months before the time when I saw him, he had squinting, and appeared to lose the power of the right arm and leg. The squinting went off after some time, but afterwards recurred occasionally. The use of the arm and leg was never entirely recovered. These always appeared weaker than the limbs of the other side, and he seldom attempted to raise the arm at all. He had also suf- fered occasionally slight convulsive affections. When I saw him there was no very marked symptom, except con- siderable emaciation: the pulse was frequent, and the bow- els very confined. Much dark-coloured matter having 122 ABSCESS OF THE CEREBELLUM. been evacuated from his bowels, he seemed to be relieved. After some days, there was a remarkable slowness of the pulse, and in the course of the same day he was attacked with violent convulsion. This recurred several times du- ring two days, and then proved fatal. There was no coma; the eyes continued sensible during the intervals; and he took notice of objects a very short time before death. Inspection.—There were several ounces of fluid in the ventricles of the brain. In the substance of the medulla ob- longata, where it is crossed by the Pons Varolii, there was an abscess which appeared to occupy its whole diameter. It had the appearance of a scrofulous abscess, and was con- tained in a cyst, the inner surface of which was of a yellow colour, and had an appearance of ulceration. There was considerable disease in the glands of the mesentery. § XIII.—Abscess of the cerebellum. Case XLIII.—A young lady, aged 18, was seized on 4th March, 1813, with inflammation of the bowels. The inflammatory symptoms were subdued by two full bleed- ings, but the bowels continued very obstinate, and were not moved in a satisfactory manner till the 12th. During this time, a variety of purgatives had been given, with repeated tobacco injections; and by calomel, given as a purgative, her mouth had been affected as early as the 7th. From the beginning of the attack, she had been affected with pain in the left ear, and about the 7th began to com- plain of headach. This was at first slight, and, amid the urgency of her other symptoms, excited little attention. It increased, however; and on the 11th had become violent, so that she lay pressing her temples with her hands, and scream- ing from pain. The pulse was at this time natural, and abscess of the cerebellum. 123 she was free from vomiting and uneasiness in the bowels. On the 11th, there was a considerable discharge of matter from the left ear. On the 13th, the pulse rose suddenly to 160, and there was such a degree of sinking as required the use of wine. The pulse soon subsided, so that on the eve- ning of the 14th it was at SO, and on the 15th at 60. The headach continued unabated. On the 14th, there was a tendency to coma, which was increased on the 15th, with dilatation of the pupil. There was now little room for ac- tive treatment; and topical bleeding, blistering, &c. were employed without relief. On the 16th, the pulse began to rise again, but was very variable, in the course of a few minutes varying from 80 to 120. She lay in a state of great oppression, but when roused talked sensibly; head- ach still severe. (18th) Had lost the power of swallowing, but often asked for drink, though she was nearly suffoca- ted in the attempt to swallow it; the pulse varying from 90 to 150. (19th) Squinting and dilated pupil; pulse varying from 96 to 160. (20th) Squinting increased; swallowed a little once or twice with effort; at other times was near- ly suffocated in attempting it; was still quite sensible when roused, and complained of violent headach. She now sunk gradually, and died on the 22d; she had conti- nued sensible when roused, and knew those about her till an hour before her death. She had also retained the sense of sight, though the pupils were much dilated. Inspection.—The surface of the brain was natural; the substance showed marks of increased vascularity, and the ventricles were distended with colourless fluid. The left lobe of the cerebellum was entirely converted into a bag of purulent matter, of a greenish colour and intolerable fetor. It was contained in a soft and organized sac, which appear- ed to be of recent formation. A portion of the dura mater on the outer side of the abscess was thickened and spongy; the bone was sound, the caput coli, and about eighteen inches 124 ulceration of the surface of the bbain. of the extremity of the ileum, were of a dark livid colour, but sound in their structure. Another case of abscess of the cerebellum has been des- cribed under a former article.—-See Case III. § XIV.—Ulceration of the surface of the brain. This appearance is uncommon, but it is distinctly de- scribed by several writers. A man, mentioned by Dr. Scoutetten, had violent headach, followed by great disturb- ance of the stomach and prostration of strength. He was relieved by topical bleedings, &c.; but after a week, the symptoms increased, with fever, and the pain was so vio- lent as to produce screaming. In this manner he went on without relief, and died on the twenty-sixth day,—no other symptoms being mentioned, excepting that he lay with his eyelids closed, and his fore-arms bent. On the lower part of the anterior lobe of the right hemisphere of the brain, there was a superficial ulcer measuring 13 lines by 7. It was of a yellowish appearance, and its edges were unequal and ragged. The dura mater and pia mater cover- ing the spot were destroyed by erosion, and the pia mater was in some other places inflamed; the brain in other re- spects was healthy. A similar appearance on the posterior part of the brain was observed in a man who died of pro- tracted intestinal disease; he had been affected for three days before his death with oedema of the forehead and left eyelid. headach, delirium, and convulsive motions of the upper extremities.* The same appearance in the cerebellum is mentioned by Mr. Howship.t A soldier at Cibraltar lay down • Arch Gen. de Med. January 1825. f Med. and Phys. Journal, March 1810. review of the subject. 125 and fell asleep in the sun in a very hot day; he soon awoke in great pain, and was confined to bed for six weeks, with constant and violent pain in the forehead. He then returned to his duty, and was not heard of for six months, when he went into the hospital again, affected with pain in the forehead. It now became remittent, generally returning every morning, but sometimes missing a day, or varying in the hour of attack; there was no fever. Two months after his admission he be- came suddenly delirious in the night, and soon after expired. On dissection, there appeared a general increased vascularity of the brain, without any decided disease, until the tentorium was raised, when there appeared upon the upper surface of the cerebellum an ulcerated superficial excavation, the size of a shilling, containing a thin ichorous matter. The pia mater at this place was destroyed, and the dura mater was discoloured. The cases described under Section V. appear to illustrate! the principal phenomena connected with inflammation of the substance of the hemispheres. In Case XXIII. we see it in its recent state on the surface of the brain, and in Case XXIV. we find it in the substance forming a distinctly defined por- tion in a state of active inflammation. In Case XXVII. we see an inflamed portion of this kind passing gradually into ra- mollissement; and in Case XXVIII. we see the ramollissement in a more advanced state. In the subsequent cases, we see more complete ramollissement, both uncombined and mixed with purulent matter. We then find the inflammation passing into a distinct and encysted abscess; and finally we observe it terminating by ulceration of the surface of the brain. Of the cause of these varieties of termination we at present know very little. I have thrown out a conjecture that the ramol- lissement occurs chiefly in the white matter, and suppuration 17 126 inflammation of the hemispheres. in the gray; but it is mere conjecture. That the ramollisse- ment however is a result of inflammation, I think the appear- ances described in some of these cases place beyond a doubt. I have already stated my belief that it also arises irom another cause, namely, disease of the arterial system, being thus ana- logous to gangrene in other parts of the body, which we see arising from these two very opposite causes. In this manner I have proposed to reconcile the diversities of opinion which at present exist among pathologists in regard to this appear- ance. In the symptoms which accompany inflammation of the substance of the hemispheres, tberc appears to be such a diversity as must prevent us at present from attempting any general statement of them. The most common appear to be headach followed by convulsion, either of one limb, or of a more general kind-; or a sudden attack of convulsion, without previous complaint of pain, the convulsed parts afterwards becoming paralytic. But in Case XXIV. no paralysis was ob- served after three days of the most frightful convulsion; while in Case XXVIII. paralysis was the first symptom, and con- vulsion took place at a subsequent period. In other cases, again, we find paralysis of one side of the body and convul- sion of the other. On this interesting subject, however, we have not at pre- sent a sufficient collection of facts to enable us to advance to any general statement in regard to the symptoms, or to re- fer particular symptoms to the particular seats or terminations of the disease. But there are numerous facts of very great interest which deserve to be recorded, without attempting any thing farther than a simple statement of them in connexion with the principal morbid appearances. They refer chiefly to the affection in the various conditions of simple inflamma- tion, ramollissement, suppuration, and ulceration; and to some interesting phenomena connected with the disease in a chro- nic form. review of the subject. 127 I. In the state of Simple Inflammation, the affection seems in general to be characterized by headach and convul- sion; but in a more chronic form of it, as in Cases XXV. and XXVI., we see it productive of paralysis without convulsion, and fatal in a state of simple inflammation, with all the symp- toms of perfect apoplexy. On the other hand, in Case XXVIII., the palsy preceded the convulsion. In some of the cases which terminated by the encysted abscess, there is rea- son to believe that the inflammatory stage was characterized by convulsion of one or more limbs, followed by temporary paralysis, and that the permanent paralysis, took place when the disease passed into suppuration. In some of the other cases, again, it seems probable that the inflammatory state was productive of an attack of palsy, exactly resembling the ordi- nary hemiplegia from other causes. This probably took place in the very interesting case, (No. XXXII.) Of the disease in its more chronic form, an important example is related by Dr. Treutler.* A woman, aged 30, had been ill for two months with dropsy, which had followed intermittent fever, and was connected with disease in the spleen. In the third month of her illness, she complained of a feeling of weight in the occiput towards the right side, with dimness of sight, and a great propensity to sleep. Her hearing became obtuse, her speech was very indistinct, and her memory was lost. She at last seemed to lose the power of every voluntary muscle, so that she could neither move her legs nor arms, nor raise her head. Finally, she had convulsions and apoplectic at- tacks, and died suddenly about the end of the third month of her illness, that is, less than a month from the commencement of the symptoms in the head. In the posterior lobe of the right hemisphere of the brain, behind the lateral ventricle, a por- tion the size of a large walnut, (fructus regiae juglandis,) was • Treutler. Auctariuni ad Ilelminthologiam Human! Corporsi, p. 1. 128 INFLAMMATION OF THE HEMISPHERES. in a state of high inflammation; the membranes adhered to the surface of the brain in several places; where this did not oc- cur, there was serous effusion under the arachnoid. There was no fluid in the ventricles; there were hydatids in the cho- roid plexus, which were most numerous on the right side. The spleen was much enlarged; and extravasated blood, to the amount of several pounds, was found in the abdomen; it was contained partly in the cavity of the omentum, partly be- tween the laminae of the meso-colon, and partly under the pcritonaeal coat of the descending colon. II. The Ramollissement of the Cerebral Substance does not appear to be characterized by any uniformity of symptoms. In particular, there does not appear to be any foundation for a statement made by some of the French wri- ters, that it is distinguished by tonic contraction of one or more limbs. This symptom occurred in Case XXVIII. at an early period, and afterwards disappeared. It is also met with in connexion with affections of the membranes, without any disease of the cerebral substance; and with the encysted ab- scess; and it is frequently observed in cases of typhus, where there is much cerebral disturbance, but which terminate fa- vourably. Lallemand* remarks that he had taken up the idea of the rigid contraction of the limbs being diagnostic of ramollissement, and was very much perplexed when he met with a case in which all the limbs were in a state of the most remarkable relaxation. The cases which terminate by ramollissement seem in ge- neral to be characterized by convulsion, more or less exten- sive, followed by paralysis and coma, the convulsion ceasing for some time before death, and being succeeded by the coma; but in Case XXVIII. the convulsion continued with the ut- • Lallemand, Recherches sur l'Encephale. review of the subject. 129 most violence till the very time of death. In Case XXXII. on the other hand, there was no convulsion, but a sudden at- tack of palsy, exactly resembling the ordinary attack of he- miplegia from other causes. In the very remarkable Cases, XXX. and XXXI. we find ramollissement of very limited extent, as the only morbid appearance, in connexion with symptoms of long standing; both cases being at last rapidly fa- tal by a sudden attack of convulsion. In some of the subse- quent cases, again, we find most extensive destruction of the cerebral substance, without either paralysis or convulsion, and even without coma. In one remarkable case to be afterwards de- scribed, namely, the last case under tubercular disease, we shall find destruction of the cerebral substance, to as great an extent perhaps as is upon record; while the patient went to bed in the state of health in which she had been for many months before her death, and was found dead on the morning. We find the same difficulty in attempting to ascertain the effect of ramollissement of particular parts of the brain, in producing symptoms in particular organs. Convulsion in the same side with the disease, and paralysis on the opposite side, appear to be frequent symptoms, but, as we have seen, by no means uniform. In several of the cases, the speech was re- markably affected, but they present no uniformity in the seat of the disease. The recovery of speech in Case XXXII. was a remarkable occurrence. In a case by Lallemand, in which the upper part of both hemispheres was affected, there was resolution of all the limbs; and in one in which the ramollissement was seated in the tuber annulare, there were squinting, resolution of all the limbs, and distortion of the head backwards. The same writer describes two cases in which the disease was in the cerebellum. In the one, there were headach, phrensy, convulsive motions, and sudden death; in the other, in which it was in the left lobe, there was loss of speech, with palsy of the right side, and stupor; it was fatal in eight days. 130 INFLAMMATION OF TnE HEMISPHERES. III. In the cases which terminate by Suppuration, we find the same diversity of symptoms as in the cases now re- ferred to. The suppuration, we have seen, varies, by being in some cases confined in a distinct encysted abscess, and in others forming an undefined mass of disease, in which purulent matter is more or less mixed with cerebral sub- stance in a state of ramollissement. In the latter form of the disease, the symptoms are often exceedingly obscure and undefined, as we see in Cases XXXIV. and XXXV. In the encysted abscess, they appear to be in general more marked and severe. The course of symptoms in Case XXXVII. was very remarkable. The sudden attack of convulsion, followed by paralysis of one arm, probably oc- curred in the inflammatory stage; for when the symptoms were relieved by the blood-letting and other remedies, the arm recovered its motion. The convulsion returned, and the paralysis along with it, and again subsided; and after several attacks of the same kind, the paralysis became per- manent. The thigh and leg then went through the same course. In such a case, it appears highly probable, that the convulsion occurs while the inflammatory state is going on, and that the period of suppuration is indicated by the per- manent paralysis. In this case, three abscesses wrere met with; but, whether the successive formation of these had any relation to the successive attacks of the disease in the arm and leg, must be matter of conjecture. In a similar case, related by Bartholinus, the leg was first affected, and afterwards the arm. One abscess only is mentioned, of which it is merely stated that it was on the opposite side. In a case by Schenkius, there occurred paralysis of the left side, and convulsion of the right; there was a superficial ab- scess on the right side of the brain. Something similar to this occurred in a case to be afterwards mentioned, (Dis- eases of Bones,) in which there was paralysis cf the left side, with convulsive agitation of the right arm. In a girl, aged REVIEW OF THE SUBJECT. 131 five, whose case is described by Dr. Bateman,"* an abscess was found in the posterior part of the right hemisphere, en- closed in a fine vascular sac, and containing four ounces of pus. She was first affected with convulsion of the whole body, which continued for nearly two days; during this time, the left side was in a state of rigid extension, and the right was in constant motion; and when the attack subsided, the left side remained paralytic. She then had headach, squinting, blindness, and repeated convulsion; and died af- ter an illness of fifteen weeks, having been comatose for only one day before death. In some cases of this kind, paraly- sis has occurred without convulsion, and in others, convul- sion without paralysis; but one or other of these affections appears to be a common attendant on the encysted abscess. In a case descrlted by Morgagni, the prominent symptoms were, pain of the left side of the head, delirium, loss of speech, and weakness of the muscles of the left side of the neck; the man died in fourteen days, gradually exhausted; and an abscess was found in the right corpus striatum which had burst into the ventricle. In a case by Valsalva, in which the disease was in the corpus striatum, the speech was much affected, and one side was paralytic. In another, there were indistinctness of speech, and paralysis of the right side, connected with an ulcerated cavity at the base of the brain on the left side. In a third case by the same writer, there were paralysis of the right side, and convulsion of the left, with an ulcerated cavity in the substance of the brain under the choroid plexus of the left side. Many other varieties occur in the symptoms, in regard to which it is unnecessa- ry to enter into any lengthened detail. In a case by Lal- lemand there were cramps of the limbs, followed by a sud- den attack of palsy of the right side. After three days the * Edin. Med. Journal, vol. i. p. 150. 132 INFLAMMATION OF THE HEMISPHERES. affected limbs were seized with convulsions, which occurred for several days, and ended in fatal coma. Another case, by the same writer, began with pain in the right side of the head and tremor of the left arm. This was followed by a continued convulsive flexion and extension of the left arm, which after some days passed into palsy. There were then some convulsive motions of the limbs of the right side; the abscess was in the right side of the brain. In a man men- tioned by Broussais, an extensive abscess was found in the centre of each hemisphere, without any other symptom than a peculiar dulness' of manner, with taciturnity, and at last coma after 37 days. In cases of a more chronic kind, the abscess is often found enclosed in a mass of tubercular mat- ter or indurated cerebral substance. These have probably supervened upon chronic disease of the brajp, which, after continuing long in an indolent state, has at length passed into suppuration. In a few cases, abscess has been found in the brain without any symptoms which indicated its exis- tence. Morgagni found one in the posterior part of the brain in a man who died of gangrene of the nates, without any symptom in the head. A man, mentioned by Dr. Powel, was received into St. Bartholomew's hospital on account of cough, dyspnoea and bloody expectoration. He died after he had been a month in the hospital, having been for some time before his death in a dozing state, with occa- sional delirium, but without coma, and he had never com- plained of his head. His lungs were much diseased, and an abscess the size of a large walnut was found in the sub- stance of the brain, under the anterior part of the corpus callosum.* In the encysted abscess of the cerebellum, the symptoms seem to be less violent than when the disease is in the brain. * Med. Trans. Coll. of Phys. London, vol. v. REVIEW OF THE SUBJECT. 133 A very slight convulsion occurred once in Case III. In Case XLIIL, the most remarkable symptom was the loss of the power of swallowing. In a case by Plancus, there was paralysis of one side, and it is stated to have been on the same side with the disease.* In Case III., though the dis- ease was in the cerebellum, the principal seat of pain was in the forehead, and this has been observed in other cases of the same kind. IV. The superficial ulceration of the brain ap- pears to be a rare occurrence, and some of the cases of it present phenomena of rather an interesting character. A man mentioned by Dr. Powel,t was affected with a convul- sive motion of the left side of his body, which very much resembled chorea; he was free from it during sleep, and had no other complaint. This affection continued five weeks, and then suddenly terminated in palsy of the affected side. Soon after this, his right hand and arm became convulsed, but in a slighter degree; he then became gradually comatose, and died two months after the commencement of the com- plaint On the anterior part of the right hemisphere of the brain, there was a superficial loss of substance from ulcera- tion, two inches in length and as much in breadth; it pre- sented an irregular excavated appearance, and a thin layer of curdled matter was deposited in it. There was a simi- lar disease, but much less extensive, on the anterior part of the left hemisphere, and there was much fluid in the ven- tricles A lady mentioned by Dr. Thomas Anderson* of Leith, had been for several years liable to headach, winch was most violent at the crown of the head. After she had * Storia Med. d'una Postema del lobo destro del cervellctto. ■j- Trans. Coll. Phys. London, vol. v. * Tran. ltov. Soc. Edin. vol. ii. 18 134 inflammation of the hemispheres. suffered for a considerable time from this pain, she was seized with a convulsive affection of the left arm and leg. It occurred in paroxysms, attacked her several times every day, and generally continued about half an hour at each time. This complaint became gradually more and more severe; the right side became slightly affected in the same manner, and she was afterwards liable to attacks of coma, in which she often lay for 24 hours at a time. She died at last of gradual exhaustion. On the upper part of the right hemisphere of the brain, there was a superficial loss of substance from ulceration, two and a half inches long, one and a half broad, and nearly an inch in depth. In the bot- tom of it there were found some thin laminae of a firm brown- ish matter, with stony concretions, some of which broke into sand on the slightest touch. The effect of superficial inflammation of the brain, or its membranes, is well illustrated by another case related by Dr. Anderson, in which the disease took place under his eye. A boy suffered, from an injury of the head, the de- pression of a considerable portion of the right parietal bone, the depressed portion being forced through the dura mater, and driven inwards upon the brain. He had paraly- sis of the left side, and the left eye was insensible. The de- pressed portion being removed, the paralysis was greatly diminished, and the eye recovered a considerable degree of vision. On the third day after the operation the wound in the dura mater was inflamed, with considerable tumefaction; and immediately the left leg and arm became paralysed, the paralysis being accompanied by convulsion; and the left eye also became insensible. He had frequent convulsion of these parts for several days, the right side not being in the least affected, when, suppuration having taken place, all the symptoms subsided. Had the disease occurred with- out such an outlet as was in this case afforded to the mat- ter, the suppuration, instead of relieving the symptoms, review of the subject. 135 would probably have induced permanent paralysis and fatal coma. A man mentioned by Mr. John Bell, suffered, from an injury of the head, extensive extravasation of blood on the surface of the brain, which was removed by repeated applications of the trephine. During the cure, which oc- cupied three months, the left side of the brain suppurated five or six times. The attack of inflammation was always accompanied by fever, stupor, and difficult deglutition; but these symptoms were removed by the suppuration. These attacks occurred at various parts of the brain. When they were towards the anterior part, he had double vision, which also was removed by the suppuration; when they were to- wards the posterior part, there was not double vision, but a state of vision in which a candle was seen with a halo around it. Ulceration of the surface of the brain I have seen only in one instance, in a preparation which was shown me by Dr. Macintosh. There were on various parts of the surface of the left hemisphere, spaces of superficial ulceration of va- rious extent, with ragged edges, and sensible loss of sub- stance. The affection occurred in a child of 18 months, and was complicated with effusion in the ventricles, and ramollissement. The pia mater and arachnoid were destroy- ed at the ulcerated spots; and the pia mater in other places was studded with minute tubercles. The symptoms were not to be distinguished from those of hydrocephalus in its ordinary form. There were also numerous granular tuber- cles in the lungs. V. The inflammation of the cerebral substance occurs in a chronic form, in which the symptoms may continue for months, and the disease then prove fatal by suppuration, or without having suppurated. In Cases XXV and XXVI. we have remarkable examples of this form of the disease proving fatal without suppuration. In Case 136 INFLAMMATION OF THE HEMISPHERES. XXV. we can have little doubt that the disease had exist- ed in the first attack, and, after a protracted illness, had been removed or in a great measure subdued. It then took place again, and was fatal with loss of speech, palsy, and coma; yet after all, it had not advanced beyond the state of simple inflammation. The progress of this more chronic form of the disease seems to differ considerably from the other modifications of it. We have seen that it may con- tinue for a considerable time in a state of simple inflam- mation, and in that state may be fatal with all the symp- toms of perfect apoplexy. It may also, after continuing for some time in this state, pass into rammollissement or suppuration; but it appears, that in some cases it terminates by induration of the part of the brain which has been the seat of it. A degree of this occurred in Dr. Hay's case, and it appears probable that as the induration advances, the inflammatory appearance subsides; the part is then left in a state of simple induration, and at a more advanced period may pass into unhealthy suppuration. This state of disease may either affect a considerable portion of the brain, from the surface downwards, or may be confined to a small cir- cumscribed portion in the substance of the hemisphere. In this case, the affected portion appears, in some instances, to be afterwards surrounded by a cyst, and this appearance has been called a tumour in the brain. It is probable that it is merely apart of the cerebral substance in a state of low scrofulous inflammation; that in its early stage, it is a dis- ease which may be cured; and that the formation around it of a cyst of coagulable lymph, or its termination by induration of the part, are the points in its progress which give it the character of organic or hopeless disease. In either of these states it may be fatal after protracted symptoms, or it may terminate by suppuration. This affection, in its first stage, was observed by Burserius in the anterior part of the right hemisphere, in a man who died after an illness of four months; REVIEW OF THE SUBJECT. 137 he had been affected with constant pain of the head near the vertex, fever, paralysis of the left side, and convulsive affections which occurred at intervals. Fantonus found a similar disease in the corpus callosum) in a man who had been long affected with epileptic paroxyms, and at last died comatose and convulsed. In the state of suppuration, Bur- serius found one the size of a pigeon's egg in the outer part of the right hemisphere under the squamous suture, in a man who had been affected for several months with intense head- ach, and convulsive tremors of the whole body, which were most severe on the left side. He found another in the pos- terior part of the brain near the tentorium, in a woman who had been ill for several months with severe headach with- out fever: the pain was so intense as almost entirely to de- prive her of sleep, and she seems to have been gradually worn out by the severity of it without any other remarka- ble symptom. This form of chronic inflammation of a small part of the brain is a disease of much interest. The symptoms may go on for several months, so as to assume the character of or- ganic disease; they may remit, so as to resemble periodical headach; the disease may be fatal with symptoms resembling apoplexy; orit maypass into permanent induration of the part affected; or, after it has appeared to resist all our remedies, it may gradually subside. This agrees exaptly with the course of chronic or scrofulous inflammation, as we observe it in external parts. We see it in the eye, in the lympha- tic glands, in the testicle, in the mamma, and in the cellular texture. It takes place rapidly, producing enlargement of the parts, and derangement of the functions; it may continue stationary for a considerable time; it may then terminate by unhealthy suppuration or ulceration, or by permanent indura- tion of the part; or, after resisting for a long time all our re- medies, it may gradually subside, without leaving any per- manent change in the organization of the part. I think 138 INFLAMMATION OF THE HEMISPHERES. there is little doubt that something of this kind takes place in the brain, and if this doctrine be admitted, the practical application of it will be, that we shall be less disposed than we usually are, to consider such cases as depending upon or- ganic disease, and consequently not the objects of active treatment. The progress of this interesting affection is well illustrated by Case XXV., and there are others on record which show it under some varieties in the symptoms. A gentleman mentioned by Dr. Powel, was affected with severe headach which occurred in paroxysms: during the paroxysms, which often continued for several hours, he had double vision, mental depression, and at one time muscular twitches and numbness of the left side. The pulse was variable, being sometimes a little frequent, and sometimes rather below the natural standard. By large and repeated blood-letting, &c. he was much relieved, but, after a short interval of relief, the complaint returned with great violence, and his vision remained permanently double. After several aggravations and remissions of this kind, he had at the end of three weeks an interval of ease for more than a fortnight. The pain then returned with violence, and was accompanied with spasmo- dic affections of the muscles of the neck. He then derived temporary relief from narcotics, and, soon after this, the complaint assumed so much of a periodical character, that it was treated by bark; the pulse at this time was natural. Un- der this treatment the paroxysms became rather less severe, but not less frequent; and they were attended occasionally by convulsive motions, which chiefly affected the right side. The paroxysms occurred at very uncertain intervals. They sometimes consisted of pain only, and sometimes of pain ac- companied by the convulsive motions. He died suddenly in a convulsive attack, two months after the commencement of the complaint; for some time he had been considered as better, and had sat up for two hours on the day preceding REVIEW OF THE SUBJECT. 139 the night on which he died. The anterior part of the right hemisphere was found much changed in its structure and indurated, so that it is described as a tumour. When the dura mater was first removed, the part thus affected appeared to rise higher than the neighbouring parts, and the cerebral substance surrounding it was very soft. The morbid con- dition here described is probably a different stage of the dis- ease which occurred in Cases XXV. and XXVI; and there was a considerable similarity in the symptoms to the first attack in Case XXV. The affection may likewise pass into a still more chronic state of induration, in which it may be protracted for a greater length of time, but producing urgent symptoms; and may at last be fatal by suppuration, or without having sup- purated; or, if it be seated in the superficial parts of the brain, it may terminate by the ulceration of the surface formerly referred to. A man mentioned by Dr. Anderson, received a violent blow on the back of his head, from the boom of a ship, which fell upon him as he was stooping under it. After some time he had pain in the part, which became gradually more severe, and, after eighteen months, brought on convul- sive paroxysms of both upper and lower extremities, the vio- lence of which put an end to his life, after he had suffered from them for several months. Both hemispheres of the brain at the posterior part \yere found inflamed and much hardened. The diseased parts* adhered closely to the dura mater, and to the falx; and the dura mater at that part was thickened and indurated. A man, aged 45, mentioned by the same writer, had been liable for several years to convulsive paroxysms resembling epilepsy, but with this peculiarity, that the convulsion was confined to the right arm and leg. The attacks occurred at irregular intervals, generally once in three or four weeks, and were succeeded by stupor which continued about half an hour. Without any change in the complaint he was killed by an injury of the head. A portion of the left 140 INFLAMMATION OF THE HEMISPHERES. hemisphere of the brain wa- found indurated, and closely ad- hering to the dura mater, which at that place was much thick- ened and hardened. Extravasated blood was found in ano- ther part of the head, which appeared to have been the effect of the injury, and the immediate cause of death. In a man, aged 35, who had suffered for several months from violent pain in the forehead with epileptic paroxysms, Morgagni found the anterior part of the right hemisphere of the brain indurated, and adhering to the dura mater. Baader relates the case of a man, aged 40, who became suddenly epileptic, with pain at a particular part of the left side of the head. There was exquisite sensibility of the surface of the left hand and arm, so that the slightest breath of cold air upon them brought on convulsive twitches. After an illness of five years he died rather suddenly. At the part which had been the seat of pain, there was superficial induration of a portion of the brain, and under the indurated part there was an abscess the size of an egg. From the imperfect view now given of this subject, I think it will appear, that the inflammation of the cerebral substance is an affection deserving accurate investigation. There is every reason to believe, that it exists in various degrees of ac- tivity; that in the most active form it advances speedily to ra- mollissement or suppuration; but that it also exists in a chro- nic form, in which its progresses very slow, so that it may produce urgent symptoms for a considerable length of time, without having advanced beyond that stage in which there is a chance of recovery. This latter form we have seen reason to believe may afterwards pass into suppuration, or may ter- minate by induration of the cerebral substance, and may thus assume the characters of organic disease. The disease may affect any part of the brain, and often appears to commence in a very small portion of it, and to extend gradually over a larger portion. It appears to be in cases of this kind that wc chiefly meet with some singular examples of gradual paraly- REVIEW OF THE SUBJECT. 141 sis, beginning perhaps in a very slight degree, or in a single muscle, and advancing very gradually to more perfect and more extensive palsy. A small part of the brain in such cases is probably undergoing this low state of inflammation, gradu- ally gaining ground, and at length terminating either by fatal coma or permanent paralysis. In the palsy connected with these inflammatory affections, there is sometimes, especially in the early stages, violent pain in the affected limbs. In some cases, again, the loss of power is accompanied by total loss of feeling; in others, the feeling remains entire; and some remarkable examples are met with, in which the feeling is morbidly increased. A case of this kind has been already referred to; another is mentioned by Lallemand. In this case there had been, after a blow on the head, headach, impaired intellect, and weakness of the limbs. Six weeks after, there was a sudden attack of loss of speech, with palsy of the right side, and increased sensibility of the parts, so that a touch was painful. Ten days after this, there was an attack of palsy of the left side, with fatal coma. There was an appearance of inflammation and extensive ramollisse- ment of the cerebral substance of the left side, and on the right side, extravasation of blood, which had obviously been the origin of the fatal attack. The disease occurs in the cerebellum in the same chronic form which has now been referred to in regard to the brain ; it in some cases exhibits nearly the same symptoms, and in others the symptoms are extremely obscure. A man men- tioned by Mr. Douglas had been for three months affected with pain in the forehead, which generally obliged him to sit with his head leaning forward; he had bad appetite and disturbed sleep, but no other symptom. He died suddenly in an attack resembling syncope, having been for a day much better, with good appetite and quiet sleep. An encysted ab- scess was found in the middle of the cerebellum, and a rup- ture of the left lateral sinus, which probably was the imme- 19 142 INFLAMMATION OF THE HEMISPHERES. diate cause of death.* A man, mentioned by Serres,t after a blow on the back and lateral part of the head, which stunned him at the time, had a certain unsteadiness in walking, which made him always anxious to take the arm of a friend; and he had a delicacy of his head, which made him much affected by a small quantity of wine. This continued about eighteen months, when he became sad and irritable, with trembling of the limbs. Soon after, the left leg became paralytic, and the arm of the same side was numb and weakened. After the insertion of a seton in the neck, the arm recovered, and three months after this, the patient died with fever, delirium, and an affection of the bowels. There was disease in the right lobe of the cerebellum, with an abscess and extensive soften- ing. In another man, mentioned by the same writer, who died in forty days, there was palsy of the right leg with wasting of the limb, but without loss of sensibility, the arm being little if at all affected. There was ramollissement of the left lobe of the cerebellum, occupying chiefly the centre of the left pe- duncle. SECTION VI. INFLAMMATION OF THE CENTRAL PARTS OF THE BRAIN,— THE CORPUS CALLOSUM, SEPTUM LUCIDUM, FORNIX, AND THE MEMBRANE LINING THE VENTRICLES. The morbid conditions which I mean to consider under this head, embrace the various forms of disease which have usually been included under the term acute hydrocephalus. In venturing to refer them to a place in the general arrange- * Edin. Med. Ess. and Obser. vol. vi. f Recherches Sur Le Cervelet—Journal dc Physiologie, 1822-23. INFLAMMATION OF THE CENTRAL PARTS. 143 ment of the inflammatory affections of the brain, I may per- haps be considered as advancing too rapidly to a conclusion in regard to the pathology of this important class of diseases. But from all that I have observed of the affections themselves, and from the analogy of the corresponding diseases in other parts of the brain, I have now very little hesitation in arranging them in this manner. I shall state the grounds which have induced me to take this view of the subject, and, confining myself in a great measure to a faithful relation of facts, shall merely propose the inquiry as one of much interest for farther observation. The disease seems to present itself under two different forms. In the one, the inflammation appears to be seated in the membrane lining the ventricles; in the other, in the white matter forming the fornix, septum lucidum, and corpus callo- sum. In the former case, we find the ventricles filled with a turbid or milky fluid, sometimes containing shreds of coagu- lable lymph, and sometimes having entirely the characters of purulent matter. These appearances are often combined with a deposition of flocculent matter or false membrane on the surface of the choroid plexus, or on the inner surface of the membrane lining the ventricles, and sometimes with ra- mollissement of the cerebral matter immediately surrounding them. In the latter case, the affection presents itself in the form of ramollissement or white pulpy degeneration of the parts affected. The septum lucidum is found perforated by a ragged irregular opening, from the softened portion having fallen out. The fornix has lost its consistence in the same manner; and either has lost its figure, by having fallen down into a soft irregular pulpy mass, or, retaining in some degree its figure, while it is not disturbed, falls asunder when the most gentle attempt is made to raise it. The lower part of the corpus callosum is often affected, though, I think, more rarely than the other parts; and there is frequently a similar degeneration of the cerebral matter immediately surrounding 144 INFLAMMATION OF THE CENTRAL PARTS. the ventricles. It is generally, but not always accompanied by effusion in the ventricles of limpid fluid. The substance which is the product of the disease, is of a pure white colour, without fetor, and without the slightest resemblance to puru- lent matter. It sometimes shows a slightly fibrous texture, but in general is entirely of a soft pulpy consistence without any cohesion of parts. From all that I have observed of this affection, I have no hesitation in considering it as the termination of inflammation in these particular parts. It is an appearance of very fre- quent occurrence, and seems to hold an important place in the pathology of the brain, and particularly in the pathology of acute hydrocephalus. A most interesting point in the history of it is, that it may be fatal without effusion, and without any other morbid appearance, though with all the symptoms which are usually considered as indicating acute hydrocephalus. The first case of it which I shall present seems to establish the inflammatory origin of the affection, by showing the perforation of the septum lucidum, surrounded by a ring of inflammation; I shall then show it as the only morbid appearance in cases which were fatal with the usual symptoms of acute disease in the brain; and finally, shall sub- mit a selection of cases, showing its connexion with serous effusion in the various forms of acute hydrocephalus. In re- gard to the pathology of this affection, 1 may also refer to the facts formerly adduced with respect to the ramollissement in other parts of the brain. Some of them seem to furnish the most satisfactory evidence of the inflammatory origin of this appearance, by enabling us to trace in the same mass, one part in a state of inflammation, and another in a state of ra- mollissement, and the one distinctly passing into the other. I shall begin this part of the subject by an example of an affection, which seems to be rare—inflammation confined to the membrane lining the ventricles. INFLAMMATION OF THE CENTRAL PARTS. 145 § I.—Inflammation of the membrane lining the VENTRICLES. Case XLIV.—A child, aged ten months (January, 1819,) had fever, starting and vomiting; tongue white; bowels obsti- nate. After a week the symptoms abated; his sleep became calm, and he was at times playful; but the vomiting continued with frequent pulse. In this manner, he continued without any remarkable change* in the symptoms for nine or ten days; he then became affected with squinting and blindness, and very rapid pulse, and the vomiting continued; he died three days after the occurrence of these symptoms, and death was preceded by a slight convulsion. Inspection.—The ventricles were distended with six ounces of fluid, which was turbid, and contained in it flakes of yellow coagulable lymph. The lining membrane of the ventricles was thickened, and was easily separated by dis- section: its inner surface was covered by a thick coating of soft yellow adventitious membrane. The septum lucidum appeared to be thickened, and the pineal gland was distend- ed with a greenish fluid. On the posterior part of the ce- rebellum, the arachnoid, to the extent of a crown piece, was thickened and covered by adventitious membrane; betwixt it and the pia mater at this place, there was some deposition of puriform matter. A case considerably similar to this in the morbid appear- ances, is related by Golis,* though the progress was much more rapid, and the symptoms were more violent. A child aged 14 months, after a restless night, was seized with vio- lent fever and general convulsion, which subsided after to- pical bleeding, but soon returned with great violence, ac- * Golis on Hydrocephalus Acutus, Case II. 146 INFLAMMATION OP THE CENTRAL PARTS companied by spinal cramps, hemiplegia, blindness, dilated pupil, and distortion of the face; he died the same night, about thirteen hours after the attack. The ventricles con- tained three ounces of turbid fluid; the inner surface of the ventricles and the surface of the choroid plexus were covered by adventitious membrane; and a similar deposition was found on the corpus callosum, and on the convolutions of the brain. The same appearance is mentioned by this author in several other cases. Inflammation must have existed in the same part in a case formerly described (Case XIV.,) in which, along with extensive meningitis, there was purulent matter filling the ventricles. Morgagni describes a case in an adult, in which the left ventricle was found full of purulent matter without any disease of the cerebral substance. The charac- ters of this case were fever, apoplectic symptoms, delirium, convulsions, and palsy of the right side. $11.—The inflammatory origin of the ramollisse- ment of the septum lucidum. Case XLV.—A girl, aged 6, about two months before her death, had a violent and obstinate diarrhoea, by which she was much emaciated; after three or four weeks it abated considerably, and for a fortnight she was better. She was then seized with severe pain of the belly, vomiting and headach, the bowels being rather obstinate. The pain of the head was violent, and chiefly referred to the forehead. The pulse was from 30 to 40 in a minute, and there was a constant convulsive motion of the right arm and leg. With- out any remarkable change in the symptoms, she sunk gra- dually into stupor, and died after two days of perfect coma, about a fortnight from the commencement of the headach. The convulsive motion of the right arm and leg continued through the whole course of the disease, and almost to the moment of death. The pulse continued from 30 to 40 in a mi- FATAL WITHOUT EFFUSION. 147 nute until a few days before her death, when it rose to 70, and occasionally to 80. Inspection.—The ventricles of the brain were distended with colourless fluid. In the septum lucidum, there was a ragged irregular opening from loss of substance, and the opening was surrounded by a ring of inflammation. The inner surface of the ventricles was in a state of high vascu- larity, and the cerebral substance immediately bounding them, was in some places considerably softened and broken down. In the anterior part of the left hemisphere, a por- tion of the brain was dark-coloured and firmer than natural, and some small hard tubercles were imbedded in it. The inner surface of the caput coli and of the ascending colon was of a dark red colour, and large patches were elevated into a dark red fungus. § III.—Ramollissement of the central parts fatal WITHOUT EFFUSION. Case XLVI.—A woman, aged 30, (18th June, 1816,) was affected with violent pain in the head, which extended across from temple to temple. She was extremely restless, tossing from one side of the bed to the other, owing to the in- tensity of the pain; eyes slightly suffused, and impatient of light; pupils contracted; the pulse 60, soft and rather weak; tongue white. She was bled repeatedly, both generally and topically, and used purgatives, cold applications to the head, blistering, &c. For three days she appeared much relieved; the violent pain was removed, and she complained of pain only when she moved her head; pulse from 80 to 90. She was quite sensible, but considerably oppressed and inclined to lie without being disturbed. On the 22d, her speech was affected; she was sensible of it herself, and said that "she felt a difficulty in getting out her words;" pulse 112. (23d and 24th,) Increasing stupor, and at times incoherence, but, when 148 RAMOLLISSEMENT OF THE CENTRAL PARTS roused, she answered questions distinctly; double vision; made no complaint, but said her head was better. Pulse from 112 to 120. (25th,) Increasing stupor. (26th,) Complete coma and dilated pupil; pulse 108 and of good strength; died in the night. Inspection.—The fornix and septum lucidum were broken down into a soft white pulpy mass. There was no effusion in the ventricles, and no other disease in any part of the brain. Case XLVII.—A man, aged 36, a blacksmith, had been for some months affected with pectoral complaints, which were considered as phthisical. On the 10th of November, 1818, being suddenly told of the death of his daughter, who died of phthisis, he instantly complained of headach; and, af- ter another day or two, a remarkable change was observed in his temper, which became uncommonly fretful and iras- cible. He still complained of constant headach, which was much increased by motion; his pulse varied from 70 to 110. In this state he continued for a week, without any alleviation of the headach. In the second week, he began to be slightly delirious, with a tendency to stupor, the headach continuing very severe. He became gradually more and more oppressed, and at last comatose; and, after perfect coma of four days' continuance, died on the 27th. His pectoral symptoms had entirely subsided after the commencement of the complaints in his head. I did not see this patient during his life, but was present at the examination of the body. Inspection.—The membranes of the brain were very vas- cular. There was no effusion in the ventricles beyond the usual quantity. The septum lucidum was much broken down, and a large opening was formed through the centre of it. The fornix was reduced to a soft white mass, which could not be raised. There was no other morbid appear- ance in any part of the brain. The lungs were extensive- ly tubercular, and in some places suppurated. FATAL WITHOUT EFFUSION. 149 The two cases now described are the only examples which have occurred to me, of the ramollissement of the septum and fornix being fatal without any other morbid appearance. The only cases in which I find it taken notice of by other writers are, one by Senn and one by Lallemand. In the case of M. Senn,* the patient was eleven years of age. Af- ter some days of fever, with pain of the belly and vomiting, she complained of violent pain in the forehead, which was constant and severe for several days; and, after a day or two, was accompanied by dilated pupil, and distortion of the eyes upwards. This was followed by delirium and a spasmodic retraction of the head; she died on the eighteenth day of the disease, without perfect coma. The ventricles of the brain contained but a few drops of fluid. There was extensive ramollissement of the corpus callosum, septum lucidum, and fornix, without any change of colour of the parts. The vessels of the membranes were distended with blood; there was no other morbid appearance in any part of the brain. The patient of M. Lallemand! was a woman of 40 years of age, who died after an illness of about four- teen days; the principal symptoms were, fever with violent delirium, and convulsive movements. There was extreme loquacity for some days, afterwards somnolence and con- traction of the limbs, with extreme sinking. The brain was found entirely" sound, with the exception of the corpus callosum and fornix, which were transformed into a species of white pulp. * Senn, Recherches sur la Meningite Aiguc des Enfans, Case VIII. f M. Lallemand, Recherches sur l'Encephale, tome i. p. 184. 20 150 RAMOLLISSEMENT OF THE CENTRAL PARTS § IV.—Ramollissement of the central parts combined WITH SEROUS EFFUSION, CONSTITUTING THE MOST COMMON FORM OF ACUTE HYDROCEPHALUS. Case XLVIIL—A boy, aged 12, (August, 1818,) had been for several weeks observed to be languid and declining in strength, with some cough and pain in his breast. A fortnight before death, he began to complain of his head, and was then first confined to bed. After a week, when he was first seen by a medical man, he still complained much of his head, was oppressed, and answered questions slowly and heavily; had some diarrhoea and frequent pulse. The op- pression increased, and four days before his death he lost his speech and the power of the right side. This was fol- lowed by blindness and perfect coma, and he died about the 14th day from the commencement of the affection of the head, the pulse having continued uniformly frequent through the whole course of the disease. Inspection.—All the ventricles were distended with fluid; the septum and fornix were so completely broken down, that the two lateral ventricles and the third ventricle seemed to form one cavity; there was also extensive ramollissement of the cerebral substance on the anterior part, so that the cavity thus formed by the ventricles extended within half an inch of the anterior part of the brain. Case XLIX.—A boy, aged 7, (October, 1818,) had fe- ver, and headach, which was referred chiefly to the back part of the head; and the bowels were obstinate. After six or seven days, the pulse came down to the natural standard. The headach continued without any remarkable symptom till a few hours before his death, when he fell into a gene- ral state of tonic spasm of the whole body. He died after WITH EFFUSION OR ACUTE HYDROCEPHALUS. 151 continuing in this state two or three hours about the 14th day of the disease. There had been in this case no coma, but he had continued quite sensible till the attack of the convulsive affection. Inspection.—The ventricles were distended with fluid, and there was extensive ramollissement of the septum and fornix, and of the cerebral matter immediately surrounding the ventricles. Case L.—A strong young man, aged 20, (18th Septem- ber, 1814,) was affected with violent headach, extreme restlessness and some delirium; face flushed; pulse 60. He had been unwell so as to keep the house for a week, but had been only occasionally in bed; the symptoms had been much increased for two days; pulse on the former days from 80 to 90. Large and repeated blood-letting, and the other usual remedies, were employed with activity. (19th and 20th,) No improvement; violent headach, and a good deal of delirium; pulse from 75 to 80. (21st and 22d,) Less delirium; pulse 80. (23d and 24th,) Continued better; pulse from 80 to 84. (25th,) A tendency to stupor; began not to know those about him. (27th,) Perfect coma, in which he lay for four days, and then died. His pulse had continued from 75 to 84. Inspection.—Much fluid in the ventricles, and a good deal found in the base of the skull. The fornix was broken down into a shapeless mass of white pulpy matter. From similar destruction a large opening had been formed in the septum lucidum, and there was also considerable softening of the cerebral matter immediately surrounding the lateral ventricles. There was a deposition of JaTse membrane on the upper surface of the cerebellum. Case LI.—A man, aged 21, (3d Sept. 1816,) was af- 152 ACUTE HYDROCEPHALUS. fected with violent headach, impatience of light, and fre- quent vomiting; had an oppressed look, with a fixed ex- pression of his eyes; pulse 70 and strong; had been ill six days; and for three days had vomited almost every thing he had taken. After blood-letting and the other usual re- medies, his headach was very much relieved, and he was free from vomiting for two days. On the 7th, he was free from headach, and his look was natural; but his pulse had fallen to 48, and he had occasionally double vision. On the 9th, he was sitting up and dressed, his pulse 60. He was free from headach; tongue clean, and he had some ap- petite, but the double vision was constant. (10th,) Vision natural, in other respects as before. (11th,) Pulse 96; made no complaint, but his look was vacant, and the pupils were dilated; there had been some delirium in the night. (12th,) Pulse 96; considerable delirium, vision natural. (13th,) Increasing stupor. (14th,) Perfect coma, pulse 120. Died on the 15th. Inspection.—All the ventricles were distended with fluid. The fornix was broken down into a soft pulpy mass which could not be raised. The other parts of the brain were healthy. Case LII.—A gentleman, aged 21, had been for some time affected with cough and occasional haemoptysis. In the beginning of December, 1823, he began to complain of headach; he was not confined, but, on the contrary, walked in one day a distance of eight or nine miles after the head- ach began. The headach increased gradually, but he was not confined till about the 7th day. From the 7th to the 14th day, he wa*confined chiefly to bed, complaining prin- cipally of sickness and giddiness, and occasional vomiting. On some days there was headach; on others, little or none. On Monday the 15th, he was up and dressed for some hours, ACUTE HYDROCEPHALUS. 153 but had double vision. On the 16th, he was oppressed and much disposed to sleep; the double vision continued. I saw him for the first time on the 17th; he was then al- most entirely comatose, with squinting, the pulse below 60. On the 18th, after free purging, he revived considerably, and answered questions distinctly; squinting and double vision continued, with dilated pupil; he made no complaint of his head. On the 19th, the pulse began to rise; and there was a good deal of incoherent talking. On the 20th, there was constant incoherent talking, with a small rapid pulse, and he died in the night. From the commencement of the head symptoms, his pectoral complaints had entirely disappeared. Inspection.—There was partial ramollissement of the septum lucidum and of both the thalami; the ventricles were distended with fluid; the lungs were extensively tubercular, and there were several small cavities containing a bloody fluid. Before leaving this subject, it may be right to add a few cases illustrative of some of the most important varieties in the symptoms, and showing the disease at various ages and under various circumstances. Case LIII.—Sudden attack of coma without previous headach—the pupils dilating on the admission of light. —A. stout boy, aged 6, had been for several days feverish and complaining of pain in his belly. After the operation of laxative medicine, his pulse came down to the natural standard; he continued languid and listless, but made no complaint of any uneasiness, and had never been heard to complain of headach. About the 5th or 6th day of his ill- ness, 10th July, 1816, without any farther warning, he was found in the morning in a state of perfect coma, speechless, and his pupils much dilated; pulse 120. He continued in 154 ACUTE HYDROCEPHALUS. this state of perfect coma, with frequent convulsive motions of the left arm and leg, for six days, and then died, his pulse having continued steadily at 120 and upwards. On the 12th and 13th, being the 9th and 10th days of the dis- ease, the pupils, which were partially dilated, were distinct- ly observed to dilate farther upon the admission of light. Inspection.—The ventricles contained about four ounces of fluid. There was extensive ramollissement of the sep- tum and fornix, and of the cerebral substance immediately surrounding the ventricles; this was most remarkable on the left side. Case LIV. — Two distinct periods of coma.—A boy, aged 13, (13th June, 1822,) had slight headach, with some vomiting and fever. After four days, the head?.ch increased and the pulse fell to 60.—5th day, Coma. He came out of the coma on the following day, and the only prominent symptom was remarkable obstinacy of his bowels, which was only got the better of after two days by repeated doses of croton oil; he then seemed much relieved, made very little complaint of his head, was quite free from stupor, and the pulse was natural. On the following day, he complained rather more of his head, then relapsed into coma, and died on the 12th day after some convulsion. Inspection.—The ventricles were distended with fluid, and there was extensive ramollissement of the fornix and septum, and of the lower part of the corpus callosum. Case LV.—Hydrocephalus, with Hemiplegia.—A girl, aged 3, after being three days languid and complaining of some headach and pain in the bowels, was first confined to bed on the 4th June, 1822. She was oppressed, the pulse 100; there was some vomiting, and she complained of head- ach, which seemed to be referred chiefly to the right side of the head. For a week the usual remedies were em- ACUTE HYDROCEPHALUS. 155 ployed, and there was little change in the symptoms. On the 13th, complete palsy took place in the left arm and leg, which continued from this time entirely motionless, except at one time when they were moved by convulsion. After this, she fell into a dozing state, with dilated pupil and slow pulse; but complete coma took place only two days before death, which happened on the 22d. Inspection.—The ventricles were distended with fluid. In the substance of the right hemisphere, very near the ven- tricle, there was a considerable portion in a state of complete ramollissement; and, contiguous to this, anteriorly, there was a long and narrow portion of the cerebral substance in a state of remarkable induration. Case LVI.—In an adult with very obscure symptoms and fatal after the coma had disappeared. A lady, aged 30, about the 5th June, 1824, was exposed to cold and fatigue during the flow of the menses, which ceased prematurely. After this, she was for some days observed to be remarkably languid, dull; and depressed. The pulse was natural; she complained of slight headach, but her appearance had excited an apprehension rather of aberration of mind than of any bo- dily complaint, and in this manner the affection went on for nine or ten days. I saw her on the 15th; she was then odd in her manner, abrupt and absent but quite sensible when spoken to; complained of slight headach; pulse a little frequent. On the 16th, she was much oppressed, and on the 17th, in a state of nearly perfect coma, which continued on the 18th. On the 19th, after free purging with croton oil, she came out of the coma entirely, was quite sensible to every thing, and no alarming symptom remained, except that she sometimes saw objects remarkably distorted, and sometimes double. At other times, her vision was quite natural; the pulse was fre- quent, and the tongue loaded. In this state she continued for several days; she then complained again of headach; there 156 ACUTE HYDROCEPHALUS. was occasional incoherence; the sight was more indistinct, and the pupil dilated; and the pulse was increasing in fre- quency. The pulse continued to rise, with much incoherent talking, and sinking of strength; and she died on the 25th, without coma. Inspection.—The ventricles were distended with fluid, and there was extensive ramollissement of the septum and fornix. There was no other morbid appearance. Case LVII.—Remarkable remissions and apparent convalescence. A boy, aged 7, (20th October, 1824,) com- plained of pain in the back of his head, with fever and some vomiting. Topical bleeding, purgatives, &,c. were employed, and, after being an object of some anxiety for several days, (a brother having a short time before died of an affection of the brain,) he gradually improved, and on the 27th and 28th, was free from complaint, and going about the house appa- rently in his usual health. On the evening of the 28th, he was suddenly seized with violent convulsion, which returned through the night every two hours, leaving him in the inter- vals in a state of coma; the pupils dilated, and insensible. On the 29th, he was nearly comatose the whole day, the pulse weak, and varying in frequency from 60 to 120. General and topical bleeding, purgatives, &,c. had been employed. (30th,) Became quite sensible; the eye natural; pulse still frequent. He complained slightly of the back of his head, for which more topical bleeding was employed, with purgatives. He then improved progressively; the pulse was from 80 to 90, and he was free from complaint, except that the bowels were torpid, and the stools unhealthy, and that the pupil was large, and contracted slowly on the admission of light. In this state he continued several days, when the convulsion returned with greater severity five or six times, leaving him as before in a state of coma. From this he recovered partially, but sunk gradually, and died in a few days. For two or three days ACUTE HYDROCEPHALUS. 157 before his death, there appeared to be considerable palsy of the left arm and leg. Inspection.—There was extensive effusion in the ventri- cles, and extensive ramollissement of the fornix. The right lamina of the septum lucidum was in a state of ramollissement at the anterior part, occupying about the half of it; and the left lamina was in the same condition in its posterior half: there was no perforation. An interesting modification of this affection is that which supervenes upon other diesascs, chiefly of a chronic nature, especially affections of the lungs; and the remarkable circum- stance in these cases is, that the pectoral symptoms generally cease after the commencement of the symptoms in the head. The three following cases will illustrate the principal forms of this affection. Case LVIII.—An ingenious artist, aged 30, had been af- fected for some years with cough and expectoration, which was decidedly purulent; but, though much confined to the house, he was able to attend to his business as an engraver. In the beginning of June, 1819, being one day considerably agitated in the discussion of some business in which he thought himself ill used, he felt uneasiness in his head, and soon after his speech became very indistinct. The headach increased, and was chiefly felt in the left side and back of the head, and the pain extended to the upper part of the neck; his speech continued much impaired; the pulse from 90 to 96. The usual remedies were employed, with partial and temporary benefit. The case was drawn out to nearly three weeks, without any remarkable change in the symptoms. He sunk gradually into coma, and died; the pectoral complaints having subsided as those in the head advanced. Inspection.—There was extensive effusion in the ventricles of the brain, and complete destruction by ramollissement of 21 158 RAMOLLISSEMENT OF THE CENTRAL PARTS. the septum lucidum, fornix, part of the corpus callosum, and the cerebral matter bounding the ventricles. In the upper part of each lobe of the lungs, there was a portion the size of a small orange in a state of great induration, and internally presenting an irregular mass of ulceration; the lungs in other respects were healthy. Case L1X.—A gentleman, aged 24, had been affected for about eight months with cough and expectoration. In Au- gust, 1824, he was seized with copious haemoptysis, and had frequent attacks of it during August and September. In Oc- tober this ceased, but the cough continued severe, with copious purulent expectoration and great loss of flesh and strength. In the end of November, he began to complain of headach, which continued from this time to affect him considerably, accompanied by occasional vomiting; the cough and expecto- ration continuing. From this time he became much less able for exertion than formerly, but no remarkable change was ob- served in the symptoms till the first week of January, when one evening he suddenly lost his speech. He recovered it again next day, but complained of headach, and was listless and languid. On the third day he lost his speech again, and recovered it on the fourth. He lost it again on the fifth, and on the sixth recovered it. From this time his speech con- tinued tolerably distinct, but he gradually sunk into a kind of fatuous state, with occasional paroxysms of high delirium, and repeated convulsive affections of the face and upper extremi- ties. The pulse continued nearly natural; the expression of the countenance was remarkably vacant, and he still frequent- ly complained of his head. He thus gradually sunk into coma, and died in about three weeks from the time when he first lost his speech. From the commencement of this attack his cough ceased entirely, until a few days before his death, when it returned in a very slight degree. Inspection.—There was considerable effusion in the ven- OCCURRING IN PHTHISICAL CASES. 159 tricles, and extensive ramollissement of the septum, fornix, and adjoining parts. Along the base of the brain, there was an extensive deposition of yellow adventitious membrane of considerable thickness. There was extensive tubercular disease in both lobes of the lungs, with numerous large vo- micae. Case LX.—A lady, aged 28, had been for some months in winter 1823-24 affected with cough, considerable expectora- tion, some uneasiness in the chest, great loss of flesh and strength, and quick pulse. She came to Edinburgh about the 20th of May, 1824; the cough then subsided remarkably, which was ascribed by her friends to the change of air, and in a few days it entirely ceased. She then continued pretty well till about the 27th, when she began to complain of head- ach, and for the next three days she was dull and silent, seemed absent and low-spirited, and complained that her sight was dim. She was partly in bed, but her pulse was natural. On the 31st, the pulse began to rise, and there was conside- rable incoherent talking. I saw her for the first time on the following day, the first of June; her look was then absent, va- cant, and anxious, and she talked a little incoherently, but un- derstood what was said to her; there was double vision and slight squinting, the pulse very frequent. (2d,) Sight seemed much impaired, pupil dilated, much wild talking at times, but she knew those about her, and answered distinctly when spo- ken to; pulse rapid and feeble—died in the night without coma. Inspection.—The ventricles of the brain were distended with a large quantity of fluid, and there was extensive ramol- lissement of the septum, and all the central parts. About and above the optic nerves, there was a considerable deposi- tion of coagulable lymph in a firm, dense, opaque state. The lungs were tolerably healthy in their structure, but there were 160 RAMOLLISSEMENT OF THE CENTRAL PARTS, &.C. marks of extensive chronic inflammation of the pleura on the right side, with considerable deposition of coagulable lymph. It is unnecessary to multiply cases which present no par- ticular variety in the phenomena; those which have been de- scribed will probably seem sufficient to illustrate the princi- pal forms of this affection, and at the same time to exemplify some of the most remarkable varieties in the symptoms. From a fair and candid review of the whole subject, I think we can have little hesitation in concluding, that this is the ordinary form of the disease, which is commonly called acute hydro- cephalus; that it is originally an inflammatory affection, chiefly seated in the substance of the central parts of the brain; that it generally terminates by ramollissement of these parts, com- bined with serous effusion in the ventricles; and that it may be fatal by the ramollissement alone, even of small extent, but with all the symptoms which are commonly considered as characteristic of acute hydrocephalus. The cases likewise exemplify various important varieties in the symptoms. We have seen in some of them, perfect coma of long continuance without any effusion; and in others, extensive effusion without any degree of coma. We have seen again the coma entirely removed, and yet the disease go on to its fatal termination. We have seen every variety in the state of the pulse, of the vision, and of the intellectual functions; and we have seen the disease run its course without any complaint of pain or any symptoms indicative of danger, until the patient was unex- pectedly found in a state of profound coma. These and many other varieties, presented by the cases which have been described, show us the danger of being guided by system in our diagnosis of affections of the brain, and the necessity that there still is for extensive and careful observation of facts in regard to this class of diseases. CASES OF SIMPLE EFFUSION. 161 The form of the disease which has now been described, I conceive to be the more common modification of acute hy- drocephalus; but it is to be kept in mind that serous effu- sion takes place in the brain under other forms. In some of these it is connected with inflammatory affections of other parts of the brain or of the membranes; but it may take place without exhibiting any other appearance, excepting the simple effusion. As a contrast to the cases now de- scribed, I shall add two examples of hydrocephalus which presented simply serous effusion in the ventricles, with- out any other morbid appearance in the brain; and, with regard to these two cases, I think it right to add, that they are the only examples of this kind which I find among my notes of cases of idiopathic hydrocephalus. It will be seen that they exhibit the disease in its most insidious and chro- nic form, and present a remarkable contrast to the active symptoms in some of the former cases. § V.—Cases of simple effusion. Case LXL— A boy, aged 9, was affected with slight headach, foul tongue, bad appetite, and disturbed sleep; pulse from 96 to 100. The first week of his illness was passed with these slight symptoms; he was one day better and another rather worse; his headach was sometimes gone for a great part of the day, and never severe. Towards the end of the second week, there appeared to be a want of correspondence in the symptoms, the headach being greater and more permanent than accorded with the degree of fe- ver; but, even in the 13th and 14th days, the complaint had still much the appearance of the mildest form of con- tinued fever, and was considered in that light by a physi- cian of the first eminence. During the second week, how- ever, the headach had become more severe, while the other 162 CASES OF SIMPLE EFFUSION. febrile symptoms had been diminishing. On the 15th day the pulse sunk rather suddenly to 70; and the headach was increased. On the 16th day, there was a slight convulsion. On the 17th, there was coma, with some squinting; the pulse below the natural standard. On the 18th, the pulse began to rise, and the coma was diminished. On the 19th and 20th, he was distinct and intelligent, tongue clean, some appetite, pulse 96. On the following day, his ap- pearance was less favourable: he then sunk gradually into coma, with squinting, and died about the 30th day of the disease. The pulse had risen to 120, and in the last week there had been some slight return of convulsion. Inspection.—All the ventricles of the brain were found distended with clear serous fluid; there was no other mor- bid appearance, except considerable turgidity of vessels on the surface of the brain. Case LXII.—A gentleman, aged 24, was affected with slight headach, and unusual listlessness and inactivity. He ascribed the complaint to cold, and for the first week con- tinued to attend to his business. In the second week, he had considerable headach, shivering, debility, bad appetite, foul tongue, and disturbed sleep, pulse about 112. To- wards the end of this week, his friends observed once or twice a slight and peculiar forgetfulness. In the third week his pulse came down rapidly to 72; his tongue became clean; he made little or no complaint of his head, but there was occasionally a degree of incoherence, which w?s slight and transient, and a singular forgetfulness on particular sub- jects, which was observed by his friends, but did not ap- pear in his intercourse with his medical attendants. The pulse continued slow for two days, and then rose rapidly to 130, with increase of delirium. After a few days more, the delirium again subsided, and great hopes were enter- tained of his recovery; but the delirium soon returned, and CASES OF EFFUSION FROM INJURIES. 163 was rapidly followed by blindness, coma, and death. He died about the middle of the fourth week of his illness. I did not see this patient during his life, but was present at the examination of the body. Inspection.—All the ventricles of the brain were found distended with clear serous fluid, without any other morbid appearance. The pathology of cases of this kind is perhaps more ob- scure than that of the cases formerly referred to; but that, in these cases likewise, the effusion arises from a low degree of inflammatory action in the brain, is probable from the fact, that similar appearances are occasionally met with in those instances in which the disease supervenes upon injuries of the head, as in the following cases. Case LXIII.—A man, aged 40, of a scrofulous habit, was standing on a cart at Leith races, when the horse moving forward, he lost his balance and fell out of the cart, striking his head upon the sand. He felt at the time no inconve- nience, and for a week attended to his business, but com- plained frequently of headach. He was then confined to the house from increase of headach, with vomiting, and slight fever: after a few days, he became oppressed, then comatose, and died at the end of the second week. Inspection.— All the ventricles of the brain were found distended with serous fluid, without any other morbid ap- pearance. Case LXIV.-A girl aged 13, fell from a swing, and struck her head with some violence on the ground. From that time she complained of headach, but was not confined nor was her health otherwise affected, until six weeks after the accident, when her headach increased and was accom- 164 GENERAL REVIEW OF THE SUBJECT. panied by vomiting and frequent pulse. The vomiting soon subsided, but was followed by slight delirium, and this by coma. She lay in a state of coma for five or six days; and then died, two months after the fall. Inspection.—All the ventricles of the brain were found distended with serous fluid, without any other morbid ap- pearance. A general review of this important subject seems to lead to some results of much practical importance in the patho- logy of affections of the brain, particularly in regard to that class of them which terminates by effusion. There are many facts on record, which show us the presence of fluid in the brain in large quantity, without any alarming symptom having resulted from it. Morgagni found eight ounces in a man who died suddenly of suffocation in an advanced stage of pneumonia; and Dr. Heberden found the same quantity in a man who died suddenly, after being weakened by a febrile attack, without any symptom of an affection of the brain. It is therefore not the mere presence of a certain quantity of fluid in the brain, that gives rise to the symp- toms of hydrocephalus; and, on the other hand, we have seen a disease go through all the usual symptoms of hydro- cephalus; and terminate fatally without any effusion. The fair conclusion from these facts appears to be, that the pro- minent symptoms in these cases are not the result of the ef- fusion, but of that disease of the brain of which the effusion is one of the terminations. From a variety of facts which have been adduced, there seems little reason to doubt that this disease is of an inflammatory nature. If these conclusions shall be considered as well founded, it will follow, that our practice ought to be directed principally to subduing the inflammation at its earliest period, and preventing it from passing into effusion, and particularly from passing into tiENERAL REVIEW OF TITE SUBJECT. 165 ramollissement, which we have seen to be a fatal termi- mination of the disease, even though of small extent and with- out any effusion. This termination, I think, we have every reason to consider as the result most to be dreaded in this class of the inflammatory diseases of the brain; for in regard to the mere effusion, were the parts otherwise in a healthy state, there does not seem to be any very satisfactory reason for considering it as a hopeless affection. In other words, I mean to submit, that we have no good reason for doubting the possibility of serous fluid being absorbed from the ventri- cles of the brain. We are warranted in this supposition, both by the analogy of other serous cavities, and by what we ac- tually see take place in the brain itself. In the other serous cavities, we have every reason to believe, that there is con- stantly going on an absorption of the old fluid, and a depo- sition of new fluid in its place; and we see them in a state of disease, relieve themselves by an increased ab- sorption from an access of fluid which has been deposited. The ventricles of the brain are unquestionably to be con- sidered as serous cavities: and there seems to be no good reason for considering them as differing in their functions from the other cavities of the same kind, whatever the par- ticular apparatus may be by which the function is carried on. In regard to the actual existence of absorption in the brain, we have the most satisfactory proof, in the gradual disappear- ance of coagula of blood, both from the surface and from the ventricles, and from cavities in the substance of the brain. Upon the whole, I think we have sufficient ground for receiv- ing the following conclusions in regard to this class of affec- tions of the head. 1st, That in the ordinary cases of hydrocephalus, the coma and other symptoms attending it are not to be considered as the direct effect of the effusion, but of that morbid condition of the brain of which the effusion is the consequence. 22 166 INFLAMMATION OF THE CENTRAL PARTS. 2d, That we have no certain mark which we can rely upon as indicating the presence of effusion in the brain. Slowness of the pulse followed by frequency, squinting, dou- ble vision, dilated pupil, paralytic symptoms, and perfect coma, we have seen exist without any effusion. 3d, That all these symptoms may exist in connexion with a state of the brain, which is active, or simply inflammatory, while the disease is the subject of active treatment, and while by such treatment, adopted with decision at an early period, we have the prospect of arresting its progress in a consider- able proportion of cases. The ground of prognosis in parti- cular cases depends perhaps in a great measure upon the ac- tivity of the symptoms. The more they approach to the character of active inflammation, our prospects of cutting them short will be the greater; and the more they partake of the low scrofulous inflammation, it will be the less. In all of them, the period for active practice is short, the irreme- diable mischief being probably done at an early period of the disease. These principles bear immediately upon the question, Has hydrocephalus been cured? There is no doubt that many cases have recovered, which exhibited all the usual symptoms of it, several examples of which will be mentioned in the sequel. Such cases have by some been confidently brought forward as examples of hydrocephalus cured, while others have only considered them as remarkable from their singular resemblance to that disease. If the principles now referred to be admitted, we shall see reason to believe, that we have no certain rule by which we can decide upon the presence of effusion in the brain; but that all the symptoms usually attending it exist in connexion with an inflammatory condition of the brain, which, if allowed to go on, would probably lead to effusion, but which, if treated with deci- sion in its early stage, may, in a certain proportion of cases be treated with success. Whether the fluid can be absorbed CAUSES. 167 or the disease cured, after effusion has taken place, must re- main matter of conjecture; but from the facts which have been adduced, we have every reason to believe, that, in the ordinary cases of hydrocephalus, the removal of the fluid, if it did take place, would in no respect improve the situation of the patient,—because there would still remain that deep- seated disease of the central parts of the brain, which accom- panies the effusion in so large a proportion of cases, and which we have seen may be fatal without any effusion, yet with all the usual symptoms of hydrocephalus. SECTION VII. OF THE CAUSES OF THE INFLAMMATORY AFFECTIONS OF THE BRAIN. In a great proportion of the cases of the inflammatory affections of the brain, the causes elude our observation: the circumstances under which they most frequently occur, are chiefly the following: I. They often appear in the course of other febrile dis- eases, as continued fever, scarlatina, measles, &c. One of the most frequent and most severe examples of the disease arising from this source, is an affection which supervenes upon scarlatina. A child recovering from scarlatina, which may have been in a mild form, is seized, perhaps after some exposure to cold, with headach, which after a short time is followed by convulsion, and this by blindness and coma. These symptoms may have been preceded by the anasarca which frequently supervenes upon scarlatina, and on that account, are apt to be ascribed to sudden effusion in the 168 INFLAMMATORY AFFECTIONS OF THE BRAIN. brain ; but the disease is entirely inflammatory, and the pa- tient can be saved only by the most vigorous treatment, —by blood-letting, purgatives, and other similar remedies. Upon this plan, many such cases recover; others die and present the usual appearances of the inflammatory affections of the brain; and some of those who have recovered from the affection, have been afterwards liable to epileptic parox- ysms. A similar disease occurs in continued fever, espe- cially in the more advanced stages of it. If it has come on gradually and insidiously, it is generally hopeless; if it be in a more acute form, the patient may frequently be saved by active treatment. In connexion with low and protract- ed fev§r, however, a condition frequently occurs, which puts on many characters of the most dangerous affections of the brain, but these pass off when the fever subsides. A boy, between 4 and 5, whom I saw with Dr. Begbie, with much of the character of low fever, had stupor followed by dilated pupil and blindness with some squinting; he then had loss of speech; and after lying completely speechless for nearly a month, gradually recovered. The blindness con- tinued only six days; the recovery of his speech was pre- ceded by copious discharge of matter from both his ears. About three months after, he died in the country of a head affection, and tubercular disease was found m the brain, with effusion. In another case, in an adult, which termi- nated favourably, there was for several days nearly per- fect coma, with that spasmodic rigidity of some of the limbs, which the French have considered as characteristic of ramollissement of the brain. II. They may follow injuries, and this perhaps is a more frequent cause of the affections than we are generally aware of, especially in children; the injury being often slight, and the interval very considerable betwixt it and the appearance of any alarming symptoms. I have given two remarkable ex- CAUSES. 169 ampins which seem to be referrible to this head in Cases LXI1I. and LXIV. III. Suppressed evacuations. One of the most common examples of this is suppression of the menses, which in young women of unsound constitution is very often followed by dangerous affections of the brain. Headach, or any symptom in the head occurring under such circumstances, is always to be considered as requiring most minute attention. Case LVI. affords an interesting example of the disease coming on in this manner, and running its course with a very remarkable train of symptoms. Another affection which seems to be referrible to this head, is that effusion in the brain which is apt to su- pervene upon urinary disorders, particularly on that remark- able affection, the Ischuria Renalis. In this obscure disease, the prominent symptom is a very sudden diminution of the se- cretion of urine, amounting frequently almost to a complete suspension of it. Generally about the third day from the occurrence of this symptom, the patient is found passing into a state of coma, in which after a few days more he dies. The ventricles of the brain are found distended with fluid. In the following singular case, the same symptoms supervened upon another and rather uncommon modification of the disease namely, Ischuria Ureteralis. Case LXV.—A gentleman, aged 70, (in February 1816,) complained to me that he could pass no urine; he made no other complaint, and on introducing a catheter, the bladder was found to be empty. For six days he continued in this state, keeping the house, but complaining of nothing, except once or twice, when closely questioned, of slight uneasiness in his back. On the seventh day, he had slight confusion of thought, and indistinctness of speech. On the 9th, he became comatose, and died on the 13th. On dissection, extensive ef- fusion was found in the ventricles of the brain; the bladder 170 INFLAMMATORY AFFECTIONS OF THE BRAIN. was empty. Both kidneys were distended with urine. „Both ureters were completely obstructed by large calculi, the one immediately at its upper extremity, the other about three inches below the kidney. IV.—The affections often occur in connexion with disease of a chronic or scrofulous character in other parts of the body. The most frequent example of this is, the brain becoming af- fected in the advanced stages of phthisis. Of this I have given several examples, and I have seen many more assuming va- rious characters. In one of them, the head symptoms began a month before death, with attacks of loss of speech, which continued only a few minutes at a time, and were accompa^ nied by a sensation of prickling and numbness of the right side of the face. After the patient had been liable to these attacks for a fortnight, he had headach and slight delirium, followed by stupor, which was fatal in another fortnight. In another man, aged 32, who had been ill five weeks with se- vere pulmonary complaints, the first symptom was double vision, without headach. He complained of dysuria, and his pulse was irregular. In such cases the first disease is not properly to be con- sidered as the cause of the head affection. It merely marks the tendency to inflammation of a chronic or scrofulous cha- racter; and, in habits so disposed, the affection of the brain may be excited by causes which elude our observation. On the same principle, disease in the brain may appear in con- nexion with disease of any other organ, especially in un- healthy children. In such cases the liver has often been found diseased; and, founded upon this observation, diseased liver has often been improperly stated as one of the causes of hydrocephalus. The same observation perhaps applies to worms and various other affections of the bowels, which in unhealthy children are often found to accompany hydro- cephalus, and have sometimes been considered in the rela- CAUSES. 171 tion of a cause. Some of the more acute affections of the bowels, however, seem to be entitled to more attention, though the connexion betwixt them and the affections of the brain is very obscure. In some of them, it perhaps merely arises out of the general febrile excitement of the system; but, in others, there seems to be a connexion dis- tinct from this. One of the most remarkable examples is in the inflammation of the mucous membrane of the bowels, which occurs in young children from eight to twelve months. This affection frequently terminates by coma, and the coma appears to be frequently preceded by a remarka- ble diminution of the secretion of urine. I have elsewhere thrown but a conjecture that this disease, in its relation to the affection of the brain, bears an analogy to ischuria re- nalis, but perhaps the connexion in both cases is equally ob- scure. In the dissection of cases of hydrocephalus in young children, we very often meet with intus-susceptio in the bowels, and it generally exists in several places. I have repeatedly seen six or seven of them, and in one case four- * teen. They appear in general to be quite recent, being free from inflammation or thickening of the parts; and in the cases which occurred to me, there did not exist any unusual obstinacy of the bowels. The affection, therefore, is pro- bably to be considered as recent and incidental; or perhaps, as arising out of an inversion or derangement of the peris- taltic motion of the bowels. This may be produced by the affection of the brain in the same manner as we see urgent vomiting connected with it. In some cases, however, the intus-susceptio appears to have been of longer standing, and to have preceded the affection of the brain. A girl, aged six years, mentioned by Dr. Coindet,* had severe pain in the belly, vomiting, and constipation; on the fifth day, head symptoms appeared, and she died on the 12th. Much ef- • Coindet, Memoire sur PHydrencephale. 172 INFLAMMATORY AFFECTIONS OF THE BRAIN. fusion was found in the brain, and there was an extensive intus-susceptio in the ileum, where a portion of intestine, six or seven inches long, was inflamed and thickened. V. Various other causes might be mentioned, such as passions of the mind, stimulating liquors, &c.; but I shall not enter upon these, and shall only add one which is of frequent occurrence, and presents some singular phenome- na, namely, exposure to the intense heat of the sun. It ap- pears that in some cases of this kind, the membranes are chiefly affected, and in others the substance of the brain. Sometimes an apoplectic state is produced, which is fatal in a few hours; but, more frequently, an affection of an inflam- matory nature, occasionally assuming the character of ma- nia; and in others, paralytic symptoms occur at an early period followed by coma. The affection of course is chief- ly a disease of warm climates, but also occurs in this coun- try, as in the following case, for which I am indebted to Mr. Clarkson, surgeon in Selkirk. Case LXVI.—A young man aged 15, on the 5th of June, 1818, bathed twice in the river Tweed. After coming out the second time, he lay down on the bank and fell asleep without his hat, exposed to the intense heat of the sun. On awaking, he was speechless, but walked home, and seemed to be otherwise in good health. He was bled and purged, and next day recovered his speech, but lost it again at inter- vals several times during the three or four following days. He was forgetful, and his look was dull and heavy; he made little complaint, but when closely questioned, said he had a dull uneasiness in the back part of his head. After a few days more, he had squinting and double vision, with a very obstinate state of bowels, and his pulse was 60. After farther bleeding, &c. the pulse rose to 86, but he sunk gradually into coma, and died on the 30th. TREATMENT. 173 Inspection.—The substance of the brain in general seemed highly vascular, and a very considerable extent of it was in a state of ramollissement mixed with suppuration. The ven- tricles were distended with fluid, and the membranes in many places were much thickened. The inner surface of the cra- nium was very unequal at the upper part, and one spot the size of a sixpence, was as thin as writing paper, and transpa- rent. SECTION VIII. OF THE TREATMENT OF THE INFLAMMATORY AFFECTIONS OF THE BRAIN. In the treatment of this important class of diseases the re- medies are few and simple; but every thing depends upon the use of them being adopted at an early period, and in the most decided manner. Those on which we chiefly rely are blood- letting, general and topical, active purgatives, and cold appli- cations to the head. Benefit is also derived from antimonials, and in some states of the disease from digitalis. The effect of blistering in the early stages is rather ambiguous. When it is employed, it should perhaps be on the back part of the head and neck; in these situations it is probably more likely to be useful than on the upper part of the head, while it does not interfere with a more powerful remedy, the application of cold. After the first activity of the disease has been sub- dued, blisters applied in succession to various parts of the head, and the upper part of the spine, appear to be in many cases ex- tremely useful. Mercury has been strongly recommended m that class of cases which terminate by hydrocephalus, but its reputation seems to stand upon very doubtful grounds. In many cases, especially during the first or more active stage, the in- 23 174 INFLAMMATORY AFFECTIONS OF THE BRAIN. discriminate employment of mercury'must be injurious. In the adaptation of the particular remedies to individual cases, we must of course be regulated by the age and habit of the patient, and particularly by the character of the disease in re- gard to activity. In those cases which assume the more acute or active forms, general blood-letting must be used in the most decided manner; while in cases which assume a more chro- nic character, as many of the common cases of hydrocepha- lus, it has less control over the disease, and is not borne to the same extent. In all the forms of the disease, active purging appears to be the remedy from which we find the most satisfac- tory results; and although blood-letting is never to be neg- lected in the earlier stages of the disease, my own experience is, that more recoveries from head affections of the most alarming aspect take place under the use of very strong purging, than under any other mode of treatment. In most of these cases indeed full and repeated bleeding had been pre- viously employed, but without any apparent effect in arresting the symptoms. The most convenient medicine for this pur- pose is the croton oil. In regard to local remedies, by far the most powerful is the application of cold. It may be applied in a continued manner by means of a bladder containing pounded ice mixed with a small quantity of water; but a still more effectual mode of applying it in the more acute cases, is by a stream of cold water directed against the crown of the head and continued for a considerable time, until the full ef- fect be produced from it. Applied in this manner, it is a re- medy of such power, that it requires to be used with much discretion. Under the operation of it I have seen a strong man thrown, in a very few minutes, into a state approaching to asphyxia, who immediately before had been in the highest state of maniacal excitement, with morbid increase of strength, defeating every attempt of four or five men to restrain him. The following case shows the immediate effect of it in ano- ther modification of the disease. A strong plethoric cl^ild, TREATMENT. 175 aged five years, after being for one day feverish, oppressed and restless, fell rather suddenly into a state of perfect coma. She had been in this state about an hour when I saw her; she lay stretched on her back, motionless and completely in- sensible; her face flushed and turgid. She was raised into a sitting posture, and, a basin being held under the chin, a stream of cold water was directed against the crown of the head. In a few minutes, or rather seconds, she was com- pletely recovered, and next day was in her usual health. The same remedy I am in the habit of using with the best effect in the convulsive diseases of children; and it appears to be much more useful in such cases than the warm bath, the indiscriminate employment of which is often decidedly inju- rious. In the preceding observations, I shall perhaps be consi- dered as having attached too little importance to mercury in the treatment of this class of diseases, particularly in the treat- ment of hydrocephalus; but in doing so, I have stated simply what is the result of an extensive observation. When mer- cury was first employed as a remedy for hydrocephalus, it was given with a view to promote the absorption of the effused fluid, which was supposed to constitute the essence of the disease; it is now given to correct the biliary secretion, and the functions of the digestive organs, which, according to cer- tain modern doctrines, hold so prominent a place in almost every class of diseases. In affections of the brain, as in all other diseases, it is highly proper that these secretions should be attended to, but it is not thus that we are to expect to cure hydrocephalus; and 1 confess the result of my own observa- tion is, that when mercury is useful in affections of the brain, it is chiefly as a purgative. Under the treatment which I have now mentioned, I have seen many cases recover which exhibited all the usual symp- toms of the most dangerous affections of the brain, and even the most advanced stages of them. The cases which thus 176 INFLAMMATORY AFFECTIONS OF THE BRAIN. terminate favourably form, it must be confessed, but a small proportion of those which come under the view of a physician of considerable practice; but they hold out every encourage- ment to persevere in the treatment of a class of diseases, which, after a certain period of their progress, we are too apt to consider as hopeless. I shall conclude this part of the sub- ject by a selection of cases illustrating the favourable termi- nation of the disease in various forms, and under the most un- promising circumstances. Some of these will show the af- fection arrested in the early or acute stage, while others will illustrate the favourable termination of it with the symptoms which have usually been considered as characteristic of the more advanced period, in which the affection is generally considered as hopeless. When these cases are compared with the fatal cases which have already been described, there will, I think, appear to be every reason for considering them as fair examples of this dangerous affection of the brain. Case LXVII.—A girl, aged 11, had violent headach and vomiting, with great obstinacy of the bowels, and these symp- toms were followed by dilated pupil, and a degree of stupor bordering upon perfect coma; pulse 130. She had been ill five or six days; purgatives, blistering, and mercury to salivation had been employed without benefit. One bleeding from the arm gave an immediate turn to this case; the headach was re- lieved, the pulse came down; the vomiting ceased; the bow- els were freely acted upon by the medicines which they had formerly resisted; and in a few days she was quite well. Case LXVIII.—A slender and delicate girl, aged 11, had scarlatina in a favourable form in the beginning of April, 1820. About the 16th, she was so much recovered as to be allowed to go about the house. A few days after this, she was affected with anasarca, for which she took some medicine with par- tial benefit. About the 26th, however, the anasarca had TREATMENT. 177 again increased considerably, especially in the face, which was very much swelled. In the following night she had vo- miting. On the 27th, she complained of headach, which in- creased rapidly in violence; towards the afternoon, she be- came delirious, the pulse very frequent, about 160. Soon after this she was seized with violent and general convulsion, which recurred very frequently through the early part of the night, leaving her in a state of profound coma. The treat- ment adopted during the course of these symptoms was re- peated ; general bleeding, to the amount of 28 ounces, followed by topical bleeding, purgatives, antimonial solution, &c. To- wards midnight the convulsions ceased, and some time after- wards she gradually recovered from the coma. On the 28th, she was free from any alarming symptom during the early part of the day; pulse about 108. In the evening she was seized with severe symptoms of pneumonia, on account of which she was bled during the next 24 hours to the amount of upwards of 30 ounces, besides bleeding with leeches and the other usual remedies. In a few days more she was en- tirely restored to perfect health. Case LXIX.—A young man, aged 16, in the beginning of October, 1823, had cough with severe dyspnoea, for which he was freely bled from the arm with much relief, and on the morning of the 10th, he was considered as convalescent. In the evening of that day he had headach and some vomiting. About midnight, having got out of bed to go to stool, he fell down in a state of violent and general convulsion. The con- vulsion returned during the night six or seven times with such violence that one of the attacks continued without intermis- sion for about an hour. The pulse during the night varied from 60 to 120. At first it was found impossible to bleed him on account of the violence of the convulsions, but about 7 in the morning a full bleeding was obtained, though with some difficulty, after which the convulsions ceased, except 178 INFLAMMATORY AFFECTIONS OF THE BRAIN. some slighter attacks during the day, which appeared to be arrested by pouring cold water over his head. During the 11th, he was oppressed, with occasional tremors of the limbs and some vomiting, and he had one or two threatenings of convulsion; pulse about 80 and soft: he took repeated doses of active purgatives with little effect, and on the morning of the 12th he appeared to be sinking into a state of perfect coma; pulse 50. Croton oil was now given, which operated powerfully seven or eight times. He passed a good night, and on the 13th was free from complaint. This very impor- tant case was under the care of Dr. Huie. I saw the patient along with him from midday of the 11th. Case LXX.—A gentleman, aged 21, was first affected with confusion of thought and very considerable loss of re- collection. He then complained of headach, and after a day or two had double vision, the two objects being placed the one above the other. At this time he was out of bed the greater part of the day, but was restless and confused, and at times incoherent. He was then confined to bed, and had constant headach, much incoherence and oppression, the double vision continuing. The pulse was at first frequent, but fell gradually, and sunk below the natural standard; and the symptoms went through a course exactly similar to that which has been described in many of the fatal cases. As the pulse fell in frequency, he became more and more op- pressed, until he sunk into a state of stupor, from which he could scarcely be roused so as to answer a question of the most simple kind. The case went on in this manner for eight or ten days, during which time he was treated by re- peated general and topical bleeding, cold applications, blis- tering, &c. without the smallest effect in arresting the pro- gress of the symptoms. The bowels were very obstinate, and large doses of the most active purgatives were given with little effect. He seemed to be on the brink of perfect TREATMENT. 179 coma, and the case was considered as desperate, when he began to take the croton oil, in full doses, repeated every two or three hours. In a few hours, he was purged very actively nine or ten times; the same evening he was relieved from every alarming symptom, and in a few days was free from complaint. Case LXXI.—A girl, aged 2 years and 3 months, pre- viously very strong and healthy, had recently recovered from measles, when about the 7th July, 1821, she suddenly lost the power of both her lower extremities. She continued without any improvement, but without any farther symp- tom, till the beginning of August, when she became.affected with squinting and drowsiness, and her countenance was ex- pressive of fatuity. On the 7th, she was seized with smart fe- ver, urgent vomiting, and frequent slight convulsions; the face flushed, the pulse strong and frequent. She was treated by Dr. Begbie by bleeding and purgatives; and on the 8th, she was considerably relieved. On the 9th, however, the symptoms returned, with stupor bordering upon coma, op- pressed breathing, and dilated pupil. The squinting conti- nued, with complete palsy of the lower extremities. Farther bleeding with leeches was now employed, and active purga- tives, followed by blistering on the neck, and under this treatment the more urgent symptoms speedily disappeared. The palsy of the lower extremities then subsided gra- dually and was entirely removed in about three weeks. Case LXXII.—A lady, aged 45, after the menses had ceased for four months, was seized with headach, sense of weight in the head, much oppression and double vision; the pulse was at first 72, but soon rose to 100. On the first day, she was bled to twenty-eight ounces, with little relief. On the 2d, topical bleeding, blistering, and smart purging were used, but the symptoms continued unabated. On the 3d day 180 INFLAMMATORY AFFECTIONS OF THE BRAIN. another bleeding of twenty ounces gave a turn to the com- plaint, and in a few days more, with brisk purging and spare diet, it terminated favourably. The last symptom that yielded was the double vision. It subsided slowly, the two images gradually approaching nearer to each other, but it was not entirely gone for nearly a fortnight. Case LXXIII.—A girl, aged 7, had severe headach, im- patience of light, fever and slight delirium, followed by stupor, squinting, and great obstinacy of the bowels. The tongue was at first foul, but became clean after a day or two. To- pical bleeding and blistering were employed, with various ac- tive purgatives, which produced little effect; and the symp- toms continued unabated for a week, during which she was considered as being in a hopeless state of hydrocephalus. At the end of the week, strong purging being produced, she re- covered rapidly, and in a few days was free from complaint. Case LXXIV.—A young lady, aged 11, of a family in which several had died of hydrocephalus, on September 21, 1817, had severe headach, giddiness, and much vomiting; the pulse natural. After topical bleeding and purgatives, she was relieved on the 22d. On the 23d, she still complained of headach, and the pulse fell to 60. On the 24th, the pulse fell to 50; there was much headach, with great oppression approach- ing to coma, and dilatation of the pupil. Two bleedings from the arm were now employed with much relief; the se- cond produced syncope. On the 25th, the pulse was from 80 to 90, and all the symptoms were relieved. The com- plaint then subsided under the use of purgatives and cold ap- plications; and in five or six days more she was in her usual health. Case LXXV.—A lady, aged 15, had violent headach for several days, with impatience of light, followed by transient TREATMENT. 181 fits of delirium; and this by squinting, double vision, and stu- por bordering upon coma; the bowels very obstinate, with oc- casional vomiting. The pulse was very variable, being some- times extremely frequent, and at other times little above the natural standard. There occurred paroxysms of violent ag- gravation of the pain, which produced screaming and agita- tion of the whole body, and at times there was a threatening of convulsion. This very violent case was treated by re- peated general and topical bleeding, blistering, purgatives, and mercury, given so as to affect the mouth. Under this treatment the complaint subsided; but after she appeared to be well, it suddenly returned with the same violence as be- fore, and was again treated by the same remedies. In this manner she relapsed five or six times, and at last got well after the case had been drawn out to many weeks. Case LXXVL— A lady,aged 21, in July, 1815, had symp- toms of continued fever, which went on for three weeks. The pulse then came down to 84, and the tongue became clean, but she had much headach, transient fits of delirium, and stupor bordering upon coma, and the pulse rose again to 120. In this state she continued a fortnight, with every appearance of an affection of the brain of the most formidable character, and without being at all relieved by the remedies which were employed, namely, repeated topical bleeding, blistering, and large doses of calomel. The calomel did not affect the mouth and had very little effect upon the bowels. At the end of the fortnight she was suddenly seized with copious discharge of blood from the bowels. This continued three days, and left her extremely pale and exhausted, but she was free from stupor, and the headach was much relieved. In five or six days more she was well. Case LXXVII.—A gentleman, aged 17,1st February, 1810, had symptoms of continued fever for a week; the skin then 24 182 INFLAMMATORY AFFECTIONS OF THE BRAIN. became cool and the tongue clean; but he had severe head- ach with considerable stupor; pulse 100. General bleeding was then employed, followed by purging and mercurial fric- tions; and after a few days the symptoms were allev ated; but there wa^ still much headach, with oppression, and a remark- able slowness of speech. On the 14th, there was increase of stupor; pulse 86; the tongue clean: the skin cool. On the 16th there was much incoherent talking and unmanageable deli- rium; after which the stupor again increased, the pulse con- tinuing about 84. On the 19th, there was partial relief after smart purging; but on the 20th, the stupor had returned as before, and by the 22d, had increased to perfect coma; the pulse about 100. He now lay in a state of perfect coma for four days, during which time various medicines were given with difficulty, and with little effect upon his bowels. On the 27th, purging was at last produced to the extent of four- teen evacuations in the course of the day, with complete re- lief of all his symptoms. On the 28th, there was some deli- rium, which subsided in another day. For a week he con- tinued to complain of some headach, and a feeling of weight in his head} but by the 10th of March, he was free from com- plaint. APPENDIX TO PART FIRST. The preceding observations conclude the present imper- fect outline of the first part of our subject,—The inflamma- tory affections of the brain. Before proceeding to the second part, I shall introduce in this place a few observations upon certain affections, which are most allied to the first class, and in a practical point of view are often objects of very great interest; they are referrible to the following heads : I. Tubercular Disease of the Brain. II. Certain Affections of the Bones of the Cranium. III. Certain Affections of the Pericranium. SECTION I. OF TUBERCULAR DISEASE OF THE BRAIN. When we have an opportunity of observing tubercles in the brain in their early stages, in consequence of the patient having died of some other disease, we find them presenting the same characters as in other parts of the body. They are generally solid bodies, of firm consistence, and whitish colour, varying from the size of a pin head, or a small pea, to that of a walnut or a small egg. We find them in every part 184 TUBERCULAR disease of the brain, either embedded in its substance, lying on the surface, or attached to the membranes. When they have at- tained a considerable size, they present, when cut into, the usual whitish-coloured or cheesy matter generally enclosed in a cyst; and in the fatal cases we find them more or less ap- proaching to a softened state, or partial unhealthy suppuration. They occur in persons and in families, in whom a tendency to tubercular disease has otherwise manifested itself; and they are very often combined with tubercular disease in other organs. This is remarkably exemplified in the first of the fol- lowing cases, in which all the three great cavities were at once extensively affected. The symptoms accompanying tubercular disease of the brain, in its early stages, are often exceedingly obscure and variable; perhaps little more than a tendency to headach, which assumes no formidable character, or sometimes as- sumes the appearance of what has been called the periodi- cal headach, or the sick headach. The symptoms may go on for a long time in this manner without exciting any alarm, until the disease suddenly assumes a more active cha- racter and is speedily fatal. This termination seems in ge- neral to be connected with inflammatory action of the cere- bral substance; and we find upon dissection, either extensive effusion or extensive ramollissement of that part of the brain in which the principal tubercular masses are situated. In other cases, we have every proof that masses of a very large size had existed without producing any symptoms, until an attack took place which went through the usual course of hydrocephalus. Examples of tubercular disease in the brain have already occurred in connexion with some of the dis- eases formerly referred to. I add the following cases as illustrating the affection in its more pure and simple form. Case LXXVIII.—A young lady, aged 15, fell into bad health in the beginning of the year 1822, complaining at OF THE BRAIN. 185 that time chiefly of pain in the bowels, with bad appetite; and she became languid and sallow. She went through the usual course of treatment for such affections, under the care of Mr. William Wood, with apparent benefit; but after some time she began to have cough, with uneasiness in the chest, and these symptoms then became the object of attention. Some time after this she began to complain of headach, for which she was treated with topical bleeding and blistering, and again experienced relief. In this manner, she went on for several weeks more, complaining sometimes of her belly, sometimes of her breast, and sometimes of her head. The pain was never severe in any of these situations, but she was seldom without uneasiness in one or other of them. Her bowels at first had been rather loose, but afterwards were natural, or easily kept open by mild medicines. When I saw her along with Mr. Wood, in the beginning of March, she was considerably reduced in flesh and strength; she was confined to the house, but able to be up and dressed during the day. She had a small frequent pulse, little appetite, some cough, and occasional uneasiness in the chest; there was frequent pain in the head, and febrile flushings took place in the evening. She now made little complaint of her bowels, which were easily kept open, and the stools were natural. It was evident that there was disease in all the three cavities, though it was doubtful in which of them it was to assume the fatal character, until the 15th March, when the headach became more severe, so as to confine her to bed. It then went on in the usual manner with dilated pupil, squinting and coma; and she died on the 20th. Inspection.—The ventricles of the brain were distended with fluid. In the substance of the right hemisphere, there was a tubercular mass of considerable size, partly softened; and there were several smaller masses of the same'kind in the substance of the cerebellum. The lungs were studded throughout with innumerable small tubercles, all in the so- 186 TUBERCULAR DISEASE lid state. The abdomen presented a most extensive mass of disease, the whole of the intestines being agglutinated together by adhesion; and the mass thus formed likewise adhered extensively to the parietes of the abdomen and to the omentum. Case LXXIX.—A young lady, aged 18, had enjoyed good health, except from a scrofulous sore on the left arm, till about the middle of February, 1822, when she began to complain of headach. There was fever, with oppression and loaded tongue; and the headach became so severe, that Dr. Ballingall was induced to treat her in the most active manner by general and topical blood-letting, &c. When I saw her along with him, about the end of the first week of her illness, she had still much headach, with a look of great oppression, but was quite sensible. The pain was chiefly referred to the back, of the head and neck, and was much aggravated by motion, even by being raised up in bed in the most gentle manner. The tongue was covered with a dense white crust, and the pulse was frequent and rather weak. After farther topical bleeding, purgatives, &c, there was a gradual improvement; and at the end of the se- cond week, the tongue was clean, and the look of oppression and stupor was gone. But though her general aspect was now greatly improved, she was not free from uneasiness in the head, and she did not recover strength. After an in- terval of partial relief, the headach again increased, with a look of much languor and oppression. After continuing a few days in this state, she died rather suddenly. At the morning visit of the day in which she died, she appeared sensible to every impression, and answered questions dis- tinctly when roused. Her death took place about five weeks after the original attack. Inspection.—There was considerable effusion in the ven- tricles of the brain. In the substance of the right hemis- OF THE BRAIN. 187 phere, there was a soft tubercular mass of large size; and there was considerable ramollissement of the cerebral sub- stance surrounding it. There were two smaller tumours of the same kind in the cerebellum. There were numerous tubercles in the lungs not suppurated. There was much disease of the uterus and ovaria, which were considerably enlarged; and the Fallopian tubes, in particular, were very much enlarged, and distended with a soft cheesy matter of a yellow colour. In this case it seems probable that the attack of the mid- dle of February was continued fever, and that the disease in the brain was thereby excited into action and hurried on to a fatal termination. Case LXXX.—A boy, aged 9, in January, 1821, began to complain of headach. It was usually accompanied with pain about the umbilicus, and attacked him daily, the attack commonly continuing from half an hour to two or three hours. The headach at first came on about two o'clock in the morning, and generally continued about one hour, but the period of its duration was gradually extended to three or four hours. The period of attack also gradually became later, until it advanced progressively to five in the after- noon ; it did not become later than this. The attack usually occurred every day, and generally went off with vomiting. During the attack, the pain was most violent, so as to inca- pacitate him from any exertion; but during the rest of the day, he was lively and playful, and made no complaint. He went on in this manner for six months. In the begin- ning of July, he was seized with fever and pain in the bow- els, and was confined to bed. The headach now became constant, and there was frequent vomiting. After some days the vomiting ceased, but he continued to have fever, with considerable permanent headach; and at the end of a fortnight from the commencement of the febrile attack, he 188 TUBERCULAR DISEASE died rather suddenly without coma or any affection of the senses. Inspection.—The brain was quite healthy, and there was no effusion in the ventricles. In the left lobe of the cerebel- lum, there were two tubercular masses, the size of large hazel nuts; and there was another similar tumour betwixt the two lobes; they were round and firm, and internally presented a yellowish cheesy consistence. In the thorax, there was ex- tensive adhesion, but the substance of the lungs was tolerably healthy. In the abdomen there were slight adhesions of the viscera. Case LXXXI.—A child, aged three years, of a family who had suffered much from various forms of chronic disease, had been for some months affected with a moveable swelling on the arm, of a strumous character, and was liable to discharge of matter from the left ear. He was otherwise in good health until the beginning of April, 1827, when he was observed to have a peculiar unsteadiness in his limbs in walking, and a peculiar want of control over his arms in attempting to lay hold of any object. From this time he showed a disinclina- tion to walk, but no other symptom was taken notice of till the middle of May, when he complained of pain in the back of his head, especially in the left side behind the ear. He was now confined to bed, and was fretful and feverish. On the third day from the commencement of these symptoms, he be- gan to squint, and about the same time to be affected with convulsive attacks, which generally occurred three or four times in a day; they affected at first the whole body, but af- terwards were confined to the right side, and were generally accompanied by distortion of the eyes, and a degree of stupor, which however was of short continuance; his pulse was ge- nerally about 120. He lived in this state for twelve days, and no particular change of symptoms took place, except that a few days before death the pupils became dilated and insen- OF THE BRAIN. 189 sible. He appeared to be comatose only on the last day of his life, having continued till that time to be sensible to every thing, and to take his food readily. I saw him along with Mr. Macfarlane, and all the usual remedies were employed with- out relief. Inspection.—There was considerable effusion in the ven- tricles; the brain was in other respects healthy. In the pos- terior part of the cerebellum there were two tubercles the size of large walnuts. They were situated one in each lobe, and completely imbedded in the substance of the cerebellum. Externally they were firm and of a yellow colour; internally they showed the usual appearance of unhealthy suppuration; there was extensive ramollissement in the substance of the cerebellum; and there was extensive effusion in the spinal ca- nal, both betwixt the bones and the dura mater of the cord, and betwixt that membrane and the pia mater. The substance of the cord seemed much softer than natural, especially at the upper part, where in consequence of its softness it had given way in opening the spine. The following case, for which I am indebted to Dr. Combe, of Leith, while it affords a good example of tubercular disease of the brain, is interesting from the singular coincidence of the two forms of paralysis, on the opposite sides of the face; the one connected with the division of the portio dura, the other with the disease in the brain. Case LXXXII.—A man, aged 36, about a year before his death, had a tumour extirpated from behind the angle of the jaw, on the left side, and immediately after the operation, pa- ralysis took place in the left side of the face, in consequence of which his mouth was distorted to the opposite side in a most extraordinary degree. About six months after this, he began to complain of headach, and giddiness, which often gave him the appearance of intoxication, and after some time these 25 190 TUBERCULAR DISEASE symptoms were followed by impaired vision, occasional stra- bismus, and a considerable degree of deafness; and at last by drowsiness, coma, convulsions, and death. As these symp- toms advanced, he became affected with numbness, and loss of power of the right side of the face, which increased very gradually. During the increase of this, the distortion of his mouth gradually diminished, and for some time before his death, his countenance had become entirely symmetrical. Both sides of his face were now entirely paralytic, but with this difference, that on the right side, the feeling was also lost, while on the left the feeling was entire. Inspection.—In the centre of the middle lobe of the right hemisphere of the brain, there was a tubercle about an inch long, and three-fourths of an inch in breadth. At its lower part it was attached to the cerebral substance, but the rest of it was detached, being surrounded with dark coloured pus. In the vicinity, there was increased vascularity with softening of the cerebral substance. I shall only add- on this subject one remarkable case of a tubercular mass of very great size attached to the falx, whioh must have existed for a long time without producing any symptoms. Case LXXXIII.—A boy, aged seven, had been for more than a year affected with scrofulous sores, and during that time had been in a declining state of health, without any local internal symptom, till six weeks before his death, when he began to complain of pain in the forehead, and considerable uneasiness in the abdomen. His pulse was natural, but his appetite was bad, his tongue foul, and his sleep disturbed. After the usual treatment, the pain in the belly was removed, and the headach was much relieved, so that for a fortnight he made little complaint. The headach then returned with much severity, and, without any other change in the symptoms, he OF THE BRAIN. 191 became gradually comatose, and died after three days of pro- found coma. Inspection.—There was much effusion in the ventricles of the brain, and considerable ramollissement of the cerebral substance in several places. A large firm tumour adhered by its base to the middle of the falx on the right side. It was nearly five inches in circumference at the broadest part, and about an inch and a-half in thickness. Internally, it was of a yellowish white or ash colour, and of a consistence resembling that of coagulated albumen. It was imbedded in the substance of the right hemisphere, where it had formed a depression for itself, but without any adhesion to the arachnoid of the part. There were two smaller tumours the size of large nuts, and of the same appearance, also attached to the falx,—the one at its posterior, and the other at its anterior extremity, both on the right side. Another tumour of the same kind was im- bedded in the anterior lobe of the left hemisphere, and was attached by a slender filament to the pia mater. There is reason to believe that the deposition of tubercu- lar matter in the brain, as in other parts of the body, is often the result of inflammatory action of a low scrofulous charac- ter; that it may at first be excited by injuries or other causes of inflammation; and that it may then advance gradually in a slow insidious manner. Case LXXXIV.—A boy, aged eight, in June, 1821, fell from a height and received an injury on the head, which was followed by considerable stupor. He was relieved for a time by the usual remedies; and though he was never altogether well, no remarkable symptom occurred till the m,ddle of Oc- tober, when he complained of a sense of weight in the head, followed by some stupor, with slight paralysis of the right arm and leg He continued in this state without any farther change, till the 2d March, 1822, when he was seized with severe headach, fever, restlessness, and dilated pupil. After partial 192 tubercular disease relief, by the usual remedies, he sunk gradually into coma, and died on the 17 th. Inspection.—The ventricles of the brain contained about eight ounces of fluid. In the lower part of the posterior lobe of the right hemisphere, there was a firm tumour the size of an almond. The right lobe of the cerebellum was reduced to nearly a purulent consistence. Below it, and immediately behind the petrous portion of the temporal bone, there was a tumour the size of a hen's egg, externally of a firm consist- ence, but internally approaching to suppuration. It adhered firmly to the dura mater, which was much thickened at the place of the adhesion. Case LXXXV.—A boy, aged seven, (for whose case I am indebted to the late Dr. Gregory) in the beginning of the year 1811, received a severe injury of the forehead and nose by a fall, his nose being nearly flattened by it. From this time, he complained of headach, and, after two .or three months, be- came near-sighted. Soon after, his sight became indistinct, and alter four or five months more, this was followed by blind- ness. About this time he began to be epileptic, and to be af- fected with weakness of the lower extremities, which gradu- ally increased to perfect paraplegia. He died in April, 1812, after coma of three days, his intellect having continued entire till that time. Inspection.—A firm white flat tumour, the size of a large bean, lay over the junction of the optic nerves. The ven- tricles contained twelve ounces of clear fluid. The left lobe of the cerebellum was much indurated; and the right lobe was reduced to a mass of unhealthy scrofulous suppuration. Nearly analogous to tubercular disease in the brain, appear to be those cases in which albuminous matter in a pure state is deposited in cysts in various parts of the brain, or under the membranes. The symptoms connected with some of these are very remarkable. OF THE BRAIN. 193 Case LXXXVI.—A woman, aged about 50, had been ill for a year or more before her death, during the greater part of which time she had been confined to bed, or able to be out of it only a part of the day. She was affected with violent pa- roxysms of headach, which usually attacked her in the night or about four o'clock in the morning, and generally continued for two or three hours, when it subsided, and left her tolera- bly easy till the same time the following night. Sometimes the attack was of shorter duration, going off in a quarter or half an hour. During the paroxysm the pain was most in- tense, and was sometimes accompanied or succeeded by de- lirium, and sometimes by coma of short duration; on several occasions squinting was observed. Her death was rather sud- den ; she went to bed at night in her ordinary health, and was seized with her usual paroxysm, which went off about the common time; but it returned a second and a third time, and she died early in the forenoon. Inspection.—There was considerable effusion in the ven- tricles of the brain, without any disease of the substance. Betwixt the lobes of the cerebellum, at the upper part, there was a firm white cyst containing upwards of an ounce of transparent albuminous matter of a pretty firm consist- ence, and in the lower part of the cyst there was some co- agulated blood mixed with it. Case LXXXVIL—A man, aged 50, had been for some time affected with cough and bloody expectoration. In June, 1818, he was seized with headach, and some confu- sion of thought, which appeared chiefly in a tendency to misapply words. The pain, which was referred chiefly to the forehead, increased in severity, and attacked him in violent paroxysms. The sight of his right eye was impaired, and soon after lost; and his speech became indistinct, and after some time inarticulate. Six weeks after the com- mencement of these complaints, all the symptoms wese in- 194 TUBERCULAR DISEASE creased. Violent paroxysms of pain were excited by the least motion, and even by change of posture in bed. He seldom attempted to speak, but he often pressed his hand on his forehead, and seemed to have uneasiness in his right arm. He had some squinting, with general weakness and paleness, and his intellect was evidently impaired. He died in August in a state of coma. The pulse had been usually natural, sometimes slow. Inspection.—In the substance of the left hemisphere of the brain, towards the posterior part, there was a soft and vascular cyst, containing about 5ii. of a thick colourless albu- minous fluid, coagulable by heat, and exactly resembling the albumen of an egg. The cerebral substance around the cyst was softened; the brain in other respects was healthy. The ventricles contained a small quantity of serous fluid, and had no communication with the cyst. Case LXXXVIII.—A child, aged? at the time of his death three years and a half, died in May, 1823, after having been for nearly three years affected with almost constant convul- sion. The disease began at the age of eight months, and at first assumed the form of a singular convulsive starting of the left arm and leg, compared by an intelligent surgeon who saw him at the time, to the motion which is produced by the electric shock. By degrees this passed into more regular convulsion, which afterwards affected the whole body. It occurred generally five or six times every day; occasionally there were intervals of a day or two, and at one time of two weeks; but, after such intervals, the disease generally recurred with double severity. For a year or more before death, the child had been in a state of general palsy, except an occasional motion of the left hand. He was in a state of perfect idiotism, and never attempted to speak; he swallowed food when it was put in his mouth; and occasionally expressed his wants by peculiar cries, which OF THE BRAIN. 195 his mother came to understand. Notwithstanding the complete want of voluntary power, the convulsive move- ments continued with great severity, and all the long bones of the extremities were twisted by them in a most singular manner. Inspection.—The bones were all very soft, and the long bones of the extremities singularly twisted; the head was of a natural size, and the anterior fontanelle was open. The left hemisphere of the brain, over rather more than its an- terior half, was remarkably depressed by a mass of pellucid albuminous matter, which was lodged under the arachnoid; it resembled in appearance the albumen of an egg, but was much firmer, so that pieces of it could be separated from the mass and lifted up. Parts of the mass being thrown into boiling water, became immediately opaque and coagulated. The brain in other respects was healthy. I conclude this part of the subject with the following re- markable case, showing the most extensive destruction of the substance of the brain that has ever occurred to me. It seems to have been originally a tubercular mass mixed with some masses of an albuminous character, and at last termi- nating by most extensive ramollissement. When we con- sider the extent of the disease, and the state of health of the patient a few hours before death, it is probably almost unique in the history of diseases of the brain, and shows us in a very striking manner the imperfection of our knowledge in regard to the symptoms arising from cerebral disease. Case LXXXIX.—A young lady who, between her 14th and 17th years, had suffered considerably from chronic oph- thalmia, was attacked in her 18th year with paralysis of the face. The mouth was twisted to the right side; the orbicu- laris of the left eye was affected, so that the eye could not be shut without a great effort; the sight of that eye was much 196 TUBERCULAR DISEASE impaired, and there was numbness of the whole left side of the face ; the pulse was natural. The affection had begun with pain referred to the left ear. She was bled generally and topically, and freely purged, and the affection disappeared in six or eight days. Some time after, she had a second at- tack of the same kind, which also subsided in the same man- ner. After this she became liable to attacks of giddiness, ac- companied by indistinct vision, and followed by vomiting. These attacks were of frequent occurrence, but did not in ge- neral continue above a day or two, and in the intervals she was in perfect health. These symptoms went on for about a year. In her 19th year, while she was one day sitting at dinner, she suddenly fell from her chair in a state of com- plete insensibility, with general muscular contraction or rather rigidity, but without convulsion; and in this state she remained for nearly two hours. This occurred in the month of June, 1822, and there was no recurrence of the attack till December following, when she had one exactly similar. A third took place in February, 1823; and a fourth in June of the same year. From the first occurrence of these paroxysms, the attacks of giddiness became more dis- tressing, and were then for the first time accompanied by headach, which was chiefly referred to the left temple and the left ear; and the attacks were often followed by thin wa- tery discharges from the ear. After the fourth paroxysm of the comatose affection, she began to have indistinctness of vision. At this period she used sea-bathing, by which the headach was increased, and the indistinctness of vision passed into a considerable degree of amaurosis. For the latter affection, an emetic was now recommended to her, the operation of which was immediately followed by a vio- lent attack of the paroxysm of insensibility, and these conti- nued to recur at short intervals to the time of her death. In regard to the period of their occurrence, the account of her friends was, that for a fortnight they attacked her generally OF THE BRAIN. 197 every day, and for the next fortnight she was entirely free from them. They continued to exhibit nearly the same characters as formerly described, namely, insensibility, with muscular rigidity; and there never was any appearance of convulsion, except in one instance, during the whole course of the disease. The attack generally continued from half an hour to an hour; and, except the imperfection of vision, her general health was so good, that she was married in February, 1824, which was about two months before her death. At this time she first came under the care of my friend, Dr. Ross, to whom I am indebted for the preceding history; and the leading symptoms then were, frequent re- currence of the paroxysms of insensibility, with violent head- ach, accompanied by giddiness and sickness. There was a great degree of amaurosis, but the pulse was natural, and her health in other respects good. Under the use of extract of stramonium, the paroxysms were now suspended, the vision was very much improved, and her general health and spirits were such, that the evening before her death was spent cheerfully with a party in the house of a friend. She returned home about eleven o'clock at night, and went to bed apparently in her usual health. About eight o'clock in the following morning, she was found in a state of insen- sibility with rigidity of the body; she was supposed by her friends to be in one of her usual attacks, but when she was seen by Dr. Ross, a short time after, he found that she was dead. I was present at the examination of the body. Inspection.—The brain externally appeared healthy, but when a thin section was cut from the upper part of the left hemisphere, a cavity was exposed, through which a probe passed in every direction without any resistance, through nearly the whole extent of the hemisphere. This, upon farther examination, was found to arise from the whole hemisphere being in such a remarkable state of decomposi- tion or softening, that it formed one great cyst, full of soft 26 198 TUBERCULAR DISEASE OF THE BRAIN. pultaceous matter, enclosed in a very thin covering, formed by the healthy cerebral matter on the surface. The healthy portion forming this covering, in many places did not ex- ceed a quarter of an inch in thickness; and at the thickest parts, which were on the upper surface of the brain, did not exceed one half or three-fourths of an inch. The con- tained matter was a thin soft pulp, mixed with portions of a pellucid albuminous substance, which coagulated when thrown into boiling water. This matter was chiefly in irregu- lar masses, but there were some firmer portions of it which could be separated in the form of distinct round nodules, resembling hydatids. On examination, however, they were found not to be hydatids, but uniform masses of the albumi- nous matter in a more concrete state. On the external part of the hemisphere, lying over the petrous portion of the temporal bone, there was a tumour the size of a pigeon's egg, adhering firmly to the inner surface of the dura mater. Externally, it was irregular, as if formed of a congeries of smaller tumours; internally, it was composed partly of a reddish soft flesh-coloured matter, and partly of a semipel- lucid albuminous substance, in nodules of various degrees of firmness. When thrown into boiling water, the whole mass assumed a uniform opaque white colour, and a hard cheesy consistence. The left ventricle was entire; it contained a small quantity of serous fluid, and was separated from the diseased mass by a very thin septum. The right hemisphere was healthy, except on the inner part of the anterior lobe, which was considerably softened. It appeared to every one who witnessed the dissection, that the left hemisphere had been considerably enlarged, and the right diminished in the same proportion, the falx being sensibly pressed towards the right side. The optic nerves seemed softer than natural; the cerebellum was healthy. DISEASES OF THE BONES OF THE CRANIUM. 199 SECTION IT. OF CERTAIN AFFECTIONS OF THE BONES OF THE CRA NIUM. I was led to make some researches on this subject by the following Case:— Case XC.—A woman aged 48, about a year before her death, fell down a stair, and received various injuries, espe- cially one on the head, which confined her to bed for some days. From this time her health was bad; she generally com- plained of fixed pain of the head, and had a very disordered state of the stomach and bowels. She was able, however, to attend to the ordinary duties of her family, till about three weeks before her death, when she was seized with fever and outrageous delirium. These symptoms subsided after a bleed- ing ; and next day, she had erysipelas of the face, which went off in a few days. She was then able to be out of bed, but complained of a fixed and deep-seated pain in the right side of the head, a little above the ear, and there was discharge of matter from the right ear. She continued in this state, sitting up part of every day, till three days before her death, when she became comatose, with partial paralysis of the left side, and frequent convulsive motions of the right arm. She died on the third day after the occurrence of these symptoms. Inspection.—The cranium was very easily opened, the bones being remarkably soft. On raising the skull-cap, the inner surface of the whole upper part of the cranium exhi- bited a singular state of disease. The inner table seemed to be wanting through its whole extent, and there appeared the rough, irregular, and cancellated structure of the cen- tral part of the bone. Betwixt this surface and the dura 200 DISEASES OF THE BONES OF THE CRANIl'M. mater, there was a deposition of soft adventitious membrane of a yellowish colour, varying from one-twelfth to one- eighth of an inch in thickness. In raising the scull-cap, this membrane, in some places, adhered to the dura mater, leaving exposed the irregular cancellated structure of the bone; and in other places, it adhered to the bone, exposing the dura mater of its natural appearance. The parts affect- ed by this singular state of disease were, the frontal bone above the orbitar plates, the whole of both parietal bones, the squamous portion of both temporal bones, and rather more than the upper half of the occipital bone. The great- est erosion was on the parietal bones, where several por- tions were very thin and transparent, and a few points were perforated. The external surface of the cranium was of a natural appearance, except at the few points where the ero- sion had perforated the bone by very small apertures. In the lower part of the right hemisphere of the brain, towards the posterior part, there was an extensive abscess. The brain in other respects was healthy. On the petrous por- tion of the right temporal bone, the dura mater was of a dark colour, and detached from the bone; but the bone was healthy. I find no case described by any writer exactly resembling this remarkable affection of the bone. There was a com- plete destruction of nearly the whole inner table of the cra- nium; and in its place, a deposition of a soft adventitious membrane, by which the dura mater was every where ag- glutinated to the diseased bony surface. This disease must have been going on for a considerable time; the abscess of the brain was probably recent, and the immediate cause of death. The patient was a respectable married woman, and there seemed no ground for suspecting a syphilitic taint. Such a disease therefore is probably to be considered as the result of a slow inflammatory action affecting the bone, and gradually destroying it by caries. Such a disease may ori- DISEASES OF THE BONES OF THE CRANIUM. 201 ginate in an injury, or may commence without any obvious cause. It affects most commonly the external table of the skull, though it may likewise affect the internal; but I have seen no case described by any writer in which it was en- tirely confined to the internal table. A lady mentioned by Mr. Howship,* at the age of 15, received a slight blow on the right side of the head, and for 30 years after, was liable to severe headach, which was constantly referred to that spot. She then became drowsy, and her vision was im- paired, and at the age of 50 she died comatose. At the seat of the original injury, the bone, to the extent of a crown piece, was so thin from absorption as to be almost transpa- rent. The dura mater at this part was altogether removed, and the brain beneath was of a dark livid colour, and much indurated; and this disease extended through the whole mid- dle lobe. In a case mentioned by Desault, death followed a blow on the head after a month; the bone was externally sound, and its coverings were healthy; but the internal ta- ble was blackened through the whole extent of one of the parietal bones; the dura mater adhered to the bone as firm- ly as to the other parts of the cranium; and there was sup- puration on the surface of the brain. This was probably an earlier stage of that disease which occurred in Case XC, and in a more limited form in Mr. Howship's case. A man, aged 28, whose case is related by Mr. Wathen, was affected with a swelling the size of a pigeon's egg on the left parietal bone. It gave him no pain, and continued nearly stationary for a year and a half, when a similar tu- mour appeared on the left side of the os frontis. These swellings increased, and after several weeks were united, so that they nearly covered the left side of his head. The swelling was colourless and without pain, and about this * Practical Observations in Surgery and Morbid Anatomy. 202 DISEASES OF THE BONES OF THE CRANIUM. time he suffered some convulsive attacks. Caustic was ap- plied to the posterior part of the tumour, and, when the eschar separated, the integuments were found to be two inches in thickness; and the bone beneath was extremely irregular, sending up sharp bony spiculae into the tumour, some of which were an inch in length. A similar eschar being taken out from the anterior part showed the same ap- pearances. Much thin ichorous matter was discharged from the openings, wTith some pus. He had now frequent pain and fever, with occasional convulsion and delirium; but con- tinued to go about, and could walk many miles. He died gradually exhausted, but retaining his faculties to the last, two years and a half after the commencement of the com- plaint. On dissection, the whole left side of the cranium was found perforated by numerous openings, between which there were bony ridges, filaments, and processes of a varie- ty of shapes; the sharper spiculae piercing the substance of the diseased integuments. The two largest perforations corresponded to the seats of the two original tumours, and corresponding to these there were two small abscesses in the brain. The inner surface of the bone was diseased in the same manner as the outer, and the dura mater was con- nected to it by a soft fungus, which arose from every part of the diseased bone.* Morgagni mentions extensive ca- ries of the back part of the cranium, with remarkable thick- ening of the dura mater, which originated in a blow, and proved fatal after six years; and in a young man who died epileptic, after having suffered long from intense headach, Zacchias found the inner table of the occipital bone carious to a small extent, the other table being sound. A man men- tioned by Dr. Clossy became epileptid after a blow on the head, and the fits returned several times a day for three * Medical Observations and Inquiries, vol. v. DISEASES OF THE BONES OF THE CRANIUM. 203 years. A fulness was perceived at the seat of the injury, which, being exposed by an incision, was found to be an elevation of the bone, namely, a part of the left parietal. At this place the trephine was applied, and the bone on perforating it was found "cellulous and spongy, with pus in the midst." The man died comatose a few days after the operation, and on inspection, there was found a circular asperity on the inner surface of the bone about the size of a crown piece, with several small abscesses in the membrane the size of peas.* The cases now referred to may be considered as examples of an uncommon modification of the disease of the bones of the head, in which it is principally confined to the inner table. The more common modification of it is that which occurs in the outer table, or which affects the whole depth of the bone; and some remarkable phenomena are connected with the history of the disease. It appears to be the result of a peculiar low inflammatory action, which may arise from injuries often very slight; or may commence without any obvious cause. Its progress is often extremely slow; but when it has been excited, it is impossible to conjecture how far it may extend. It may germinate by exfoliation of a part of the outer table, or may affect the whole depth of the bone; and it may extend to the dura mater and brain, and then be speedily fatal. A man mentioned by Mr. O'Hal- loran, was seized, without any injury, with a pain in the upper part of the os frontis, which increased in violence with throbbing, so as to unfit him for his employment. After nearly four months, an abscess was formed on the part, which burst; the bone was found carious, and perfo- rated by an opening, through which the dura mater could • Clossy's Observations on some of the Diseases of the Human Body, p. 204 DISEASES OF THE BONES OF THE CRANIUM. be seen covered with pus, and by this opening matter was discharged at each dressing to the amount of a table spoon- ful. The piece of bone became loose, and separated in ten days; another piece, which was also carious, was separated in another week, and in a fortnight from this time the wound was healed.* This may be considered as an example of the idiopathic form ^f the disease. The inflammatory action probably began in the pericranium, and afterwards affected the bone. The disease arises more commonly from injuries, and is often remarkably slow in its progress. A man men- tioned by the writer now referred to, received a blow on the head with a cudgel, which left some heaviness and head- ach, but without any urgent symptom, until many months after, when a tumour formed on the part, and attained the size of an apple. It was opened, and under it there was found a circular aperture in the cranium the size of a-half- crown, exposing the dura mater, which was covered with pus. After some time, a fungus arose from it; and after this had been destroyed by alum, the sore healed. A boy, aged seven, mentioned by Sir T. Cullum, fell with his head in the fire, it was supposed from a fit, and was much burned before he was observed. The consequence was an extensive eschar, which did not separate for a very long time. It then left the bone quite bare, and after three months more a separation of bone took place in one piece, consisting of the whole of one parietal bone, part of the other parietal, and part of the occipital. Granulations springing from the dura mater then presented themselves, and in six months the sore was healed, except a part about the size of the mouth of a small tea cup; the boy being otherwise in per- fect health. Between five and six years after, there was still a sore the size of a crown-piece, which discharged con- • O'Halloran on Injuries of the Head, p. 58. DISEASES OF THE BONES OF THE CRANIUM. 205 siderably; and at that time, "very little ossification had been produced towards the reparation of the injury." A remarkable circumstance in the history of disease of the bone is, that when it has once been excited, it is not always confined to the part which was the seat of the injury, but may spread gradually and extensively over other parts of the cra- nium. A lady mentioned by Mr. Norris, after a fall which pro- duced a the time no alarming symptoms, was affected with pain in the head. It generally fixed with greatest severity in the os frontis, which had been the seat of the injury; and, on that place, a tumour formed, which was opened more than three months after the fall; when the bone was found carious. The trephine was then applied, under the belief that matter might be lodged within, but none was found; the disease was confined to the bone, the dura mater being healthy. A simi- lar tumour soon after formed on the occiput, under which also the bone was found carious; after some time it exfoliated, a piece being thrown off the size of a sixpence, and the wound healed. In this manner tumour after tumour formed on va- rious parts of the head, and went through the same course. For several months pieces of the outer table only were thrown off; afterwards the whole depth of the bone was separated, at each time exposing the dura mater; and from this period the sores in the integuments did not heal. She died nine months after the commencement of the exfoliations; and on dissection portions of the scull were entirely wanting, con- sisting, as far as can be judged from the engraving, of the up- per half of the occipital bone, more than one-third of both parietal bones, and a considerable portion of both temporal bones. There was not in this case the slightest suspicion of syphilis.* A woman mentioned by Saviard, who was re- ceived into the Hotel Dieu, in consequence of an injury of * Transactions of the Medical Society of London; vol. L 27 206 DISEASES OF THE BONES OF THE CRANIUM. the head from a fall, suffered successive exfoliations of both tables of the cranium, to such an extent, that the pieces, when put together, resembled the skull-cap as it is sawn off in dis- section. This process occupied two years, at the end of which she was dismissed in good health, but with the upper part of the brain covered only by integuments. Hildanus re- lates the case of a man, on whose cranium a number of tumours formed, from which pieces of bones were discharged, at each time exposing the dura mater. The sores had healed, and the man was alive at the time when the account was written; but affected with paraplegia. Similar cases are related by Portal; in two that were under his own care, and in which he had no reason to suspect any syphilitic taint, the disease was arrested by mercury and antiscorbutics. Another peculiarity in the history of these affections is the slowness with which the bone falls into disease, and the length of time during which a disease, of small extent may exist, producing urgent symptoms, but making very little progress. A lady mentioned by M. Marechal, after a slight blow on the head, suffered constant pain in the part, often aggravated into violent paroxysms, which the most active treatment had failed to remove. After severe suffering for several years, an inci- sion was made, when a small portion of the bone was found carious. This portion was removed by the trephine, and the patient got well. The disease in this case was probably su- perficial, and it is likely that simply exposing the bone, and promoting its exfoliation, might have answered as well as this formidable operation. In other cases of this kind, the disease is at first confined to the inner table, from which it may, after a long interval, extend inwards terminating by fatal disease in the brain: some examples of this have already been referred to. In other cases, again, it appears that the disease may be first external, and afterwards, leaving its original seat, extend to the internal parts. A boy mentioned by Mr. Howship, re- ceived at school a blow on the head with a ruler. It was followed by a small sore which continued to discharge matter DISEASES OF THE BONES OF THE CRANIUM. 207 for six years. It then healed, and soon after his sight was impaired, and he became epileptic. The trephine was ap- plied at the seat of the injury without relief; he died on the third day after the operation. The bone and dura mater were sound, but the pia mater under the seat of the injury had evi- dently suffered from chronic inflammation, and the brain was much indurated through the whole extent of the middle lobe. Many surgical writers teach us that in cases in which the bone becomes diseased after wounds and injuries of the head it is the separation of the pericranium or dura mater that kills the bone. But every practical surgeon must have seen nu- merous cases in which the pericranium was separated with- out any such c )nsequence ; and others, in which the bone be- came carious, though the pericranium had not been separated. In a case already quoted from Desault, in which death fol- lowed a blow on the head after a month, the bone was ex- ternally sound and its covering healthy; the internal table was blackened through the whole extent of one of the parietal bones, yet the dura mater adhered to this portion as firmly as to the sound bone. It appears to be the inflammatory action that kills the bone, and this action, we have seen, may leave the seat of the injury, and spread from one part to another, until its progress is arrested by the powers of the constitution acting in a manner which eludes our observation, and which is very little under our control. On this principle it ap- pears, that there is in general very little encouragement for meddling with such cases by the trephine. If symptoms indicate the formation of matter beneath the bone, this must be evacuated; but perforations will remove only the danger from the lodgement of matter, and their other effects on parts thus liable to inflammatory action are extremely am- biguous. It is certain, that many cases of this kind have proved fatal soon after the application of the trephine, which had been going on for a considerable time without exhibiting any unfavourable symptom. In a remarkable case which has been reported to me by an intelligent friend, and which had 208 DISEASES OF THE BONES OF THE CRANIUM. this termination, the inner table of the skull was found on in- spection to be perfectly sound. The disease was confined to the external table, which was found to a considerable extent completely separated from the internal, being confined only by the integuments. The case had originated in a slight wound which had fallen into an ill-conditioned state, and the caries had been going on for a considerable time. Free inci- sion of the integuments is the only practice that can be re- quired in such a case, and then promoting the separation of the diseased portion of bone by the usual means. Even in the ordinary cases, so familiar to practical sur- geons, in which the formation of matter takes place within the cranium in consequence of external injuries, it is proba- ble that the main object of attention ought to be the inflam- matory action which has been excited, rather than the mere changes which are going on in the bone; and that the forma- tion of matter is to be considered not as an effect of the dis- ease of the bone, but as a result of the inflammation of parts from which the bone itself has also suffered. Cases are re- lated by Morgagni and others, in which, after such injuries, matter was formed between the cranium and the brain, with- out the least appearance of disease in the bone. The com- munication of inflammatory action from the bone itself to the brain and its membranes, is strikingly illustrated by two cases related by De Haen, in his remarks on the application of the actual cautery to the cranium. This remedy seems to have been at that time very much employed in various affec- tions of the head; and it was performed by first turning back a portion of the integuments, and then applying the cauteri- zing iron to the surface of the bone. In the two cases refer- red to, namely, a boy of 12, and a young woman of 20; this practice was employed on account of amaurosis. They both died with symptoms of cerebral inflammation; the former on the fourth day, and the latter on the fifth after the operation. On dissection, extensive inflammation of the membranes was found, with formation of matter; and in one of the cases, the DISEASES OF THE BONES OF THE CRANIUM. 509 disease had effected the substance of the brain. The cases are interesting, as showing the direct communication of in- flammatory action from the bone to the parts beneath, with- out contusion or any injury which could directly produce the death of the bone, for no caries or destruction of the bone itself was observed in either case. In the affections of the bone, which have been the subject of the preceding observations, the piece of bone, which was the seat of the disease, is in general eroded by caries through its whole extent; but a very remarkable variety of the affec- tion has been described by Professor Russel, in which the ul- cerative or carious process advances in a narrow line in a circuitous manner, so as to insulate a piece of bone of some extent, which is afterwards thrown out. The part thus se- parated is in some cases perfectly healthy, and in others is more dense than in the healthy state, being smooth and white like a piece of ivory, and without diploe. In some of these cases, the disease took place after injuries, and in others with- out any apparent cause.* Another singular variety of the affection occurs, in which after an injury of the head a portion of the bone disappears by absorption without ulceration of the integuments. A child aged nine months, mentioned by Mr. Howship, received an injury of the right parietal bone from a fall. There was no wound, and no urgent symptom at the time; but several weeks after the accident, the pulsation of the brain was dis- tinctly perceived at the seat of the injury, and the child be- came paralytic on the left side. At the age of four years, when the account was written, she had recovered the use of the left side, which had been improving gradually, and she was otherwise in good health ; but there was still a considera- ble deficiency of bone on the right side of the head, and when she cried or coughed, this part became tense and evidently Transactions of the Medico-Chirurgical Society of Edinburgh, vol. i. 210 DISEASES OF THE BONES OF THE CRANIUM. swelled. A boy aged 14, mentioned by Mr. Wilmar, received a blow on the head, which was immediately followed by a soft tumour about two inches in diameter at the base. After this tumour had continued stationary for two months, it was opened by a free incision, but discharged only blood in a fluid state. Under it the bone was found to be completely want- ing to an extent exactly corresponding to the base of the tu- mour. The wound healed favourably.* Many cases have occurred in which tumours of the dura mater have occcasioned absorption of a portion of the bone, and have appeared under the integuments. A remarkable case of this kind, which I saw along with Mr. Wishart, has been described by him in the Edinburgh Medical and Sur- gical Journal, (vol. xviii. p. 393.) Many others are on record, some of which present interesting phenomena from complications of disease. A girl, aged 19, mentioned by Mr. Hill, was first seized with numbness of the left hand, which gradually extended upwards along the arm, and was accompanied by vomiting and violent headach. After two months, the whole left side became paralytic. After ano- ther month, a small tumour like a pea appeared by the side of the bregma; which being repeatedly opened with a lan- cet, discharged matter with some relief. After seven months more, Mr. Hill found a small opening in the left parietal bone about a quarter of an inch in diameter, but which was plugged up by a hard substance from within. The trephine being applied at this place, discovered an ab- scess, which discharged four ounces of matter, and a small excrescence like a wart, which had completely plugged up the opening in the bone, and had prevented the escape of the matter. There was much relief after the discharge, but pro- trusion of the brain took place, and she sunk gradually and died in about two months, retaining her faculties till the last * Wilmar's Cases on Surgery. DISEASES OF THE BONES OF THE CRANIUM. 211 two days. Much effusion was found in the ventricles of the brain, and destruction of the brain by suppuration about two inches around the opening of the skull.* It seems proba- ble that in this singular case, the small warty excrescence on the dura mater had produced absorption of the bone, and thus afforded a partial exit to the matter. But many in- stances are on record, in which, without any cause of this kind, matter formed within the cranium has found for itself an exit through the bone; some examples of this have been already referred to; I shall only add another. A man men- tioned by Dr. M'Turk, in the Medical and Physical Jour- nal for April 1819, was affected with great derangement of the stomach and pain in the back of his head, which was much increased by motion. His sight and hearing were impaired, especially during the more severe paroxysms of pain, when his sight was nearly lost. He had continued in this state nearly a year, when a tumour formed on the sa- gittal suture, which being opened, discharged matter freely; and, on examining the wound, it appeared that there was an opening in the suture, and that the matter came from within the cranium. The wound healed gradually in a few weeks, and from that time he was free from complaint. SECTION III. OF CERTAIN AFFECTIONS OF THE PERICRANIUM. Some obscure affections of the head, accompanied by very urgent symptoms, have been found to be connected with a disease of the pericranium, the history of which presents some very singular phenomena. In the cases related by » Hill's Cases in Surgery, p. 130, 112 DISEASES OF THE PERICRANIUM. Sir Everard Home,* the symptoms in general were headach with various uneasy feelings in the head, and a painful ten- derness of the scalp at a particular spot, with some degree of swelling or thickening of the integuments at the place. In one, the sight and hearing were considerably impaired, and in several of the cases there were fits resembling epilepsy. They were treated by dividing the integuments and peri- cranium freely down to the bone, and then dressing the wounds with lint, so as to allow them to heal slowly with suppuration. In making the incision, the pericranium was found morbidly sensible, and considerably thickened; and in some of the cases, indurated, approaching to the struc- ture of cartilage. This treatment was in some of them followed by immediate and permanent relief: in others; the patient continued liable to fits or head symptoms upon any excess. In some of them, the incisions healed without any affection of the bone being discovered; in others, a portion of the bone appeared white and porous, or honey-combed, and a limpid fluid appeared to percolate through it, which re- turned immediately as often as it was wiped off. In one of these cases, the porous piece of bone exfoliated after the wound had been dressed with dry lint for six weeks; the wound then healed, and the cure was permanent. In ano- ther, after waiting eight weeks for the exfoliation, he touched it repeatedly with diluted nitric acid, after which it exfoliated and the cure was permanent. In one fatal case, he found the pericranium thickened into a mass of a fibrous bony texture, and, corresponding to this part internally, there was a simi- lar thickening and induration of the dura mater. Most of these cases had been treated by long courses of mercury with- out benefit, in some of them with aggravation of the symp- toms. • Transactions of a Society for the Improvement of Medical and Surgi- cal Knowledge, vol. iii. DISEASES OF THE PERICRANIUM. 213 This affection seems to correspond with the disease which has been described by Mr. Crampton under the name of Pe- riostitis.* Among his cases, affecting various parts of the body, there -are two remarkable examples of it in the head; the one acute, the other chronic. In the former, a boy of 14, the complaint began with a small angry tumour on the right side of the nose, from which, after some days, a swelling ex- tended along the right eyelids and forehead, with considera- ble erysipelatous inflammation and fever. On the ninth day, he became suddenly comatose, then convulsed, and died on the 12th. On dissection, the pericranium covering the fron- tal bone was found red, thickened and detached from the bone, much purulent matter lying between them. Inter- nally the dura mater was detached to an extent corres- ponding to the external disease, and a greenish puriform fluid was effused between it and the bone. The inner surface of the dura mater was also covered with pus; the pia mater was red, very vascular, and covered with pus to the extent of two inches on the part corresponding to the principal disease of the pericranium. The other case is that of a woman, aged 32, who was affected with a tumour the size of a walnut over the left parietal bone. It was soft and elastic, and its origin was ascribed to a blow six months before; there was an opening in the tumour, by which a probe could be passed down to the bone. She had intense pain in the left side of the head; the right arm was wasted and paralytic, and the fingers were contracted; both lower extremities were feeble; her speech was indistinct; she had vomiting, and frequent epileptic fits. The tumour was divided freely down to the bone, and in doing so the pericranium was found thickened, firm, fibrous, and morbidly sensible. It formed the principal part of the tumour. The bone under the tumour was found rough and superficially carious. A portion of it was removed * Dublin Hospital Reports, vol. i. 28 214 DISEASES OF THE PERICRANIUM. by the trephine, and the dura mater under it appeared very vascular, and rather thickened. For six days after the ope- ration she had fever, extensive erysipelas of the head, deli- rium, and convulsions. Suppuration was then, established, and all these symptoms were relieved. In the course of the cure a slough was detached from the dura mater. A fortnight after the operation she recovered the use of her arm, and was free from complaint. Tissot* seems to have met with this disease, and to have treated it upon the same plan, though he gives a different ex- planation of the effect of his treatment. He describes a case in which an intense pain was confined to a very small spot, at the posterior angle of the right parietal bone. It had re- sisted for a long time all the most powerful remedies, vene- section, arteriotomy, issues, cupping, &c. He cured it imme- diately and permanently, by dividing the part down to the bone, and encouraging suppuration from the wound. He ascribes the cure to the division of the subcutaneous nerves. A woman mentioned by Pouteau received a blow behind the left ear, from the immediate effects of which she soon reco- vered, but she continued to be affected with pain in the spot for four years. She then had convulsions, paralytic affections, inarticulate speech, and a long train of the most urgent symp- toms, which sometimes resembled mania, and sometimes te- tanus. She had still pain at the place of the injury, where a small portion of the integument was red, and very gentle pres- sure upon the spot produced convulsion. By a free incision down to the bone, and allowing the wound to suppurate, all these complaints were removed. A boy mentioned by the same writer received an injury on the crown of the head by a fall, at the age of eight years. A painful feeling continued in the scalp at the place of the injury, and for ten years he was liable to intense headach, which afterwards became so violent as often to occasion insensibility. At the age of 24, there was, at the upper part of the right parietal bone, the ori- • Tissot Epist. Med. Var. DISEASES OF THE PERICRANIUM. 215 ginal seat of the injury and of the subsequent uneasiness, a spot slightly red and a little swelled; the hair upon it was coarse, and stood out like bristles, and pressure upon the spot pro- duced intense pain. The pain extended to the right eye, the vision of which was obscured when the pain was violent. By a free division of the parts every symptom was removed. A similar case is related by M. Gervais, in which the pain re- turned periodically, and the patient suffered epileptic fits daily. A slight touch on the affected part produced syncope. On dividing the integuments and pericranium, the surface of the bone was found carious; this soon exfoliated, and the pa- tient recovered perfectly. Valsalva has taken notice of a remarkable thickening of the pericranium, in a case of long continued headach with occasional delirium, and at last con- vulsion. There was serous effusion in the brain; but he says nothing of the state of the dura mater or the bone. This singular affection Sir E. Home considers as beginning in the dura mater. Mr. Crampton thinks it commences in the pericranium. The latter opinion seems to be the more probable; for, in some of Sir E. Home's own cases, it was cured by simply dividing the pericranium. It appears, how- ever, that in the progress of the disease, both the bone and the dura mater are apt to be affected. The following is the best example that has occurred to me of this remarkable affection. Case XCI.—A servant girl, aged about 20, fell backwards with a child in her arms, and received the full force of the fall upon the most prominent part of the occipital bone. She soon recovered from the immediate effects of the injury, but continued to have pain in the part; and after several months, was seized with paraplegia and retention of urine. She was now confined to bed for three or four months, after which she recovered the use of her limbs in a tolerable degree, but the retention of urine continued, and she came to Edinburgh in the beginning of 1828, which was more than a year after 216 DISEASES of the pericranium. the accident. The paraplegia was now nearly removed, but she had still retention of urine, requiring the constant use of the catheter. On the seat of the injury on the occipital bone, a round portion, the size of a crown piece was acutely ten- der, and very moderate pressure upon it produced complete insensibility, which continued a minute or two, and returned as often as the pressure was repeated. It had the appearance of syncope, but the pulse was not affected. In this state I saw her along with Mr. Lizars, and it was agreed to make a free crucial incision through the part, and to keep the wound open by dressings so as to promote suppuration. In doing so, the pericranium was found tender and somewhat thick- ened, but the bone was sound. On the following day she passed her urine freely, and she continued free from complaint as long as the wound continued to discharge. It healed at the end of a fortnight, and the retention of urine returned im- mediately. The incision was now repeated with the same result as before, her urine being freely passed almost imme- diately. Various means were then employed to promote a more complete suppuration from the wound, but it healed af- ter two or three weeks, and the retention of urine returned as before, with considerable tenderness in the affected spot. A third incision was then made with the same effect as be- fore, and various applications were made with a view of pro- moting exfoliation of bone, as in Sir Edward Home's cases, but without success, and the wound again healed after three or four weeks. The fits of insensibility on pressure now re- turned, which had not returned after the former incisions, and along with them the retention of urine. Since that time repeated incisions have been made with similar results. The principal change in her situation now is, that she has got free of the fits of insensibility upon the spot being pressed; and the effect of the incisions has con- tinued longer, as on several occasions she has remained free from the retention of urine for several weeks after the inci- sions were healed, and at one time enjoyed perfect health for three months. PART II. OF THE APOPLECTIC AFFECTIONS. The remarkable condition which we call coma^ or op- pression of the brain, appears from the preceding observations to be connected with various and very different conditions of that organ. We have seen it existing with extensive effusion, and without any effusion; and we have seen extensive effusion and extensive destruction of the cerebral substance taking place without producing it. We have seen the same want of uniformity in regard to the various other morbid conditions whicih have been the subjects of the preceding observations; and, upon the whole, if we are asked, what is that condition of the brain which produces coma? I think our answer must be, that we cannot tell. We are not, however, to sit down contented with this profession of our ignorance, but ought, on the contrary, to consider this conclusion as a position of much importance, from which we are to commence a new course of investigation. In this course, putting away from us the theories which have been so often received as established principles, we must restrict our inquiries to a patient investi- gation of the phenomena of disease. In the investigation of the cases which are more properly referrible to the head of apoplexy, we find the same difficulties which have met us in the inflammatory affections. A person previously in perfect health falls down suddenly, deprived of 218 APOPLECTIC AFFECTIONS. sense and motion, and dies, after lying for some time in a state of coma. We find on examination a large coagulum of blood compressing the surface of the brain, or filling its ventricles, and the phenomena of the disease appear to be distinctly ac- counted for* Another person is cut off with the same symp- toms, and we expect to find the same appearances, but nothing is met with except serous effusion, in no great quantity, in the ventricles, or only on the surface of the brain. A third is seized in the same manner, and dies, after lying for a consi- derable time in a state of coma, from which nothing can rouse him for an instant; and on the most careful examination, we cannot detect in his brain the smallest deviation from the healthy structure. These facts have not escaped the observation of patholo- gists at various periods, and much difficulty was experienced in accounting for them upon the old doctrine of compression of the brain. Hence arose many speculations in regard to those cases in which no morbid appearance was met with on dissection, or none that was considered adequate to account for the disease. In a remarkable case of this kind, which occurred to Willis,* he supposes that the animal spirits were suddenly extinguished or suffocated by certain malignant or narcotic particles. Seelmatter ascribes the affection to a sudden relaxation of the nerves; Nicolai to a spasm of the meninges; and Lecat and Weikard to a spasm of the nerves and vessels of the brain. Kortum endeavours to reconcile the discordant opinions of his predecessors, by referring all these cases to a new species of apoplectic affections, which he styles Apoplexia Nervosa. Upon the same principle, other modifications of apoplexy have been contended for, which have been supposed to in- clude these obscure and inexplicable cases, as the Apoplexia Convulsiva, and Apoplexia Hysterica of Burserius, Tissot, * Willis De Anima Brutorum, part 2. p. 276. APOPLECTIC AFFECTIONS. 219 and other writers. Tissot mentions a woman, who, after complaining for some time of headach, was attacked with a great and sudden increase of pain, accompanied by loss of sleep, and died in a short time. On dissection no morbid ap- pearance could be detected. A young woman, mentioned by the same writer, having, during the flow of the menses, suffered from a fright, the discharge stopped, and she became liable to frequent leipothymia. After suffering from this and various other symptoms for several months, she fell into a profound sleep, from which nothing could rouse her; this con- tinued four days; she then came out of it and appeared to be recovering, when, after several days, she was seized with se- vere headach, anxiety, and convulsions, and died. No mor- bid appearance could be detected in any of the viscera. Le- cat attaches much importance to a case which occurred to him, in which, after fatal apoplexy, he found no morbid ap- pearance except a small quantity of extravasated blood, not exceeding a tea spoonful. This, he contends, could not ac- count for the disease upon the principle of pressure, but was to be considered as an effect, rather than a cause, of that spasm of the vessels, which he conceived to be the proximate cause of apoplexy. This explanation did not satisfy his con- temporaries, and various doctrines were brought forward to account for this form of the disease. Some maintained that the medullary substance of the brain is much more suscepti- ble of compression than the cineritious; but the prevailing opinion was, that there are certain parts of the brain, where, by retarding the course of the animal spirits, slight causes of compression are capable of producing the most urgent symp- toms. Hence arose a new and extensive controversy respect- ing the origin and progress of these animal spirits, and the course by which they make their exit from the brain. This important function was by one assigned to the aqueduct of Silvius; by another, to the fourth ventricle; by a third, to the infundibulum; by a fourth to the choroid plexus and straight sinus; and fatal apoplexy was supposed to be produced by 220 APOPLECTIC AFFECTIONS. very slight causes, existing at these particular parts, and even by causes so minute as altogether to elude observation. From the number and variety of these speculations, we perceive the difficulties which attend the pathology of apoplexy, and learn the important fact, that apoplexy has, by extensive ob- servation, been ascertained to be fatal without any morbid appearance, or with appearances so slight as to be altogether inadequate to account for the disease. The most simple illustration of the apoplectic state, is derived from those cases in which it is distinctly traced to an external cause, and ceases when that cause is removed. A boy mentioned by Zitzilius, had drawn his neckcloth re- markably tight, and was whipping his top, stooping and rising alternately, when, after a short time, he fell down apoplectic. The neckcloth being unloosed, and blood be- ing drawn from the jugular vein, he speedily recovered. Strangulation, when the neck is not dislocated, appears to be simply apoplexy. A man brought after execution to Sauvages was recovered by three bleedings, and sat up and talked, his breathing and deglutition being natural. After a short time the part of his neck where the cord had been applied began to swell, so as evidently to impede the circu- lation in the veins of the neck: he then became drowsy, his pulse and respiration slow, without dyspnoea, and in a few hours he died apoplectic. A woman mentioned by Wepfer recovered after execution under the same treatment. After her recovery she was for some time affected with ver- tigo, which subsided gradually. To cases such as these, we may add the numerous examples, in which persons fall down suddenly in a state of perfect apoplexy, and very speedily recover under the appropriate treatment, without retaining any trace of so formidable a malady. The apoplectic attack, as it occurs in such examples as these, must be supposed to depend upon a cause which acts simply upon the circulating system of the brain, producing there a derangement which takes place speedily, and is of- APOPLECTIC AFFECTIONS. 221 ten almost as speedily removed. What the precise nature of that derangement may be, is a point of the utmost diffi- culty to determine, and perhaps we have not data upon which it can be determined by legitimate induction. The subject leads to speculations of a very interesting kind, but it must be confessed that they are in themselves in a great measure hypothetical, and that their application to the phe- nomena of apoplexy is also conjectural in a very great de- gree. They may be worthy of some attention, but must be kept entirely distinct from our present course of inquiry; in prosecuting which, I shall now take a general view of the principal varieties of symptoms which occur in the at- tack of apoplexy. The apoplectic attack is generally preceded by symptoms indicating some derangement of the circulation in the brain. The most remarkable of these are the following;—headach, giddiness, sense of weight and fulness in the head, violent pulsation of the arteries, and confused noises in the ears. These symptoms are often accompanied by epistaxis, which may give a partial and temporary relief; by loss of recollec- tion, and incoherent talking, resembling slight intoxication; by affections of the sight, double vision, and temporary blind- ness; by drowsiness and lethargic tendency. We also fre- quently observe indistinct articulation, and other partial paralytic affections. These are sometimes confined to one limb, or part of a limb; sometimes affect the eyelids, pro- ducing inability either to shut the eye, or to open it; and frequently impair the muscles of the face, producing a slight distortion of the mouth. These symptoms, and others of a similar kind, mark the tendency to the apoplectic state, and often appear for a considerable time before the attack actually takes place. The attack itself occurs chiefly under three distinct forms, which it is of importance to distinguish from each other. 29 222 VARIOUS FORMS OF THE APOPLECTIC ATTACK. I. In the first form of the attack, the patient falls down suddenly, deprived of sense and motion, and lies like a per- son in a deep sleep; his face generally flushed, his breathing stertorous, his pulse full, and not frequent, sometimes be- low the natural standard. In some cases convulsion occurs, in others rigid contraction of the muscles of the extremities; and sometimes contraction of the muscles of the one side, with relaxation of the other. In this state of profound stu- por, the patient may die after various intervals, from a few minutes to several days; or he may recover perfectly, with- out any bad consequence of the attack remaining; or he may recover from the coma, with paralysis of one side. This paralysis may disappear in a few days, or it may subside gradually, or it may be permanent. Other functions, as the speech, may be affected in the same manner, being spee- dily or gradually recovered, or permanently lost; and re- covery from the apoplectic attack is sometimes accompanied by loss of sight. II. The second form of the disease begins with a sudden attack of pain in the head; the patient becomes pale, sick, and faint; generally vomits, and frequently, though not al- ways, falls down in a state resembling syncope; the face pale, the body cold, and the pulse very feeble. This is sometimes accompanied by slight convulsion. In other cases, he does not fall down, the sudden attack of pain be- ing only accompanied by slight and transient loss of recol- lection. In both cases he generally recovers in a few mi- nutes from the first effects of the attack, is quite sensible and able to walk, but continues to complain of headach; after a certain interval, which may vary from a few minutes to several hours, he becomes oppressed, forgetful, and incohe- rent, and then sinks into coma, from which he never reco- vers. In some cases pardysis of one side occurs, but in others, and I think the greater proportion of this class, no paralysis is observed. VARIOUS FORMS OF THE APOPLECTIC ATTACK. 223 III. In the third form, the patient is suddenly deprived of the power of one side of the body, and of speech, with- out stupor; or if the first attack be accompanied by a degree of stupor, this soon disappears; he seems sensible of his situ- ation, and endeavours to express his feelings by signs. In the farther progress of this form of the disease great variety occurs. In some cases, it passes gradually into apoplexy, perhaps after a few hours; in others, under the proper treat- ment, the patient speedily and entirely recovers. In many cases the recovery is gradual, and it is only at the end of several weeks or months that the complaint is removed. In another variety, the patient recovers so far as to be able to speak indistinctly, and to walk, dragging his leg by a pain- ful effort, and after this makes no farther improvement He may continue in this state for years, and be cut off by a fresh attack, or may die of some other disease without any recurrence of the symptoms in his head. In a fifth variety, the patient neither recovers, nor becomes apoplectic; he is confined to bed, speechless and paralytic, but in possession of his other faculties, and dies gradually exhausted, with- out apoplexy, several weeks or months after the attack. These three forms of disease frequently pass into one another; but they are very often met with, as they are here described, forming affections which differ remarkably from each other; and they appear very naturally to arrange them- selves into the three classes which have here been referred to;—first, those which are immediately and primarily apo- plectic; secondly, those which begin with a sudden attack of headach, and pass gradually into apoplexy; thirdly, those which are distinguished by palsy, and loss of speech, with- out coma. 224 VARIOUS FORMS OF THE APOPLECTIC ATTACK. SECTION I. OF THE CASES PRIMARILY APOPLECTIC. The apoplectic attack is a sudden deprivation of sense and motion, the patient falling down as in a profound sleep, the face being generally flushed, and the breathing sterto- rous. In tracing the farther history of such an attack, the following circumstances deserve our particular attention. I. In many cases the patient speedily and perfectly re- covers. II. In many cases the disease is speedily fatal, and we find on inspection extensive extravasation of blood. III. In other cases which are fatal, generally after a longer interval, we find only serous effusion, often in no great quantity. IV. In many fatal cases, no morbid appearance whatever can be detected after the most careful examination. Thus the disease, in a pathological point of view, again resolves itself into three very important divisons;—apoplexy with extravasation of blood;—apoplexy with serous effu- sion;—and apoplexy without any morbid appearance, or what I propose to call simple apoplexy. The latter affec- tion leads to speculations of very great interest; for, the phenomena of the disease appear fully to establish the im- portant fact, that there is a modification of apoplexy depend- ing upon a cause of a temporary nature, without any real in- jury done to the substance of the brain; that the condition upon which this attack depends may be removed almost as speedily as it was induced; and that it may be fatal without leaving any morbid appearance in the brain. As one of the terminations of the apoplectic attack, I have mentioned extensive extravasation of blood; but, in point of fact it will be found that this is not a common termination SIMPLE APOPLEXY. 225 of those examples which are immediately and primarily apo- plectic. The cases which terminate in this manner, in ge- neral belong to another class already referred to, and to be afterwards particularly described, which begin with a sud- den attack of violent headach, and pass into coma more gradually. The remarks to be offered under this section, therefore, will be confined to the two other forms of the disease, which seemed to be nearly allied to each other, namely, apoplexy without any morbid appearance, and apo- plexy with serous effusion. §1.__Apoplexy without any morbid appearance, or simple apoplexy. When a person previously in perfect health falls down suddenly deprived of sense and motion, and dies after lying for a certain time in a state of apoplexy, and when, on the inspection of such a case, we cannot discover in the brain any satisfactory deviation from the healthy structure, this is the affection which I propose to call simple apoplexy. I ab- stain at present from any speculations in regard to the nature of this remarkable affection, and shall confine myself to a statement of facts calculated to establish its existence as a disease of the brain, which may in this state be fatal. Case XCII.—A woman aged about 30, of a full habit, some years before her death had been affected with symp- toms in the head, accompanied by impaired speech, and par- tial loss of recollection. Some effects of this attack had con- tinued for a considerable time, especially in her speech, but by degrees she had perfectly recovered, and enjoyed excellent health for a long period preceding the attack now to be des- cribed. She was stooping over a washing tub, when she was seized with a violent fit of sneezing; she almost immediately became insensible, and would have fallen down had she not been observed and supported by some persons standing by 226 SIMPLE APOPLEXY. her, who carried her to bed in a state of perfect apoplexy. All the usual remedies were employed in the most active manner without the least effect in alleviating any of the symp- toms—she lay with all the symptoms of the most perfect apo- plexy, and died on the following day. On inspection no ves- tige of disease could be discovered in the brain, or in any other organ. Case XCIII,—A gentleman, aged 24, had been observed for some days to be dull and drowsy, and he frequently com- plained of his head. Not having appeared at his usual time one morning, his friends went into his room, and found him lying across his bed, half dressed, in a state of perfect apo- plexy. The attack was evidently recent; and it was supposed that he had been seized while he had stooped over his basin in washing. His face was rather livid, his breathing sterto- rous, his pulse slow, and of good strength. All the usual re- medies were employed with assiduity, but through the day there was no change in the symptoms. In the course of the night he recovered considerably, so as to know those about him; but in a short time after he relapsed into coma, and died early on the following day little more than twenty-four hours after the attack. Inspection.—There was a slight turgescence of the ves- sels on the surface of the brain; no other appearance of dis- ease could be detected after the most careful examination. All the other viscera were in a healthy state. For the following very important case, I am indebted to my friend Dr. Duncan; it occurred under his care in the Clinical Ward in May, 1829. Case XCIV.—A man, aged 54, of a plethoric habit and short necked, was admitted into the Clinical Ward on the 30th May. He was in a state of nearly perfect coma, speechless, and with palsy of the right side to such ai* extent, that even the in- SIMPLE APOPLEXY. 227 tercostal muscles of that side did not act. The leg and arm of the left side were occasionally affected with convulsive motions. Breathing stertorous—deglutition much impaired. Pulse 74. The affection was of three days' standing, and had come on with vertigo—loss of vision—violent headach and vomiting. All the usual remedies were employed in the most judicious and active manner without benefit. On the 1st of June, there seemed to be a slight return of intelligence, but he soon re- lapsed into coma, and died on the 3d, without any change in the other symptoms. Inspection.—A most minute and careful examination was made of the brain, without discovering any appearance of dis- ease, except that the choroid plexus seemed rather darker than usual, and the basilar artery was diseased at one spot. By the side of the artery, there was a spot of the cerebral substance, no larger than a barley corn, which appeared some- what softened, but even this Dr. Duncan considered as ex- tremely doubtful. These, I think, may be considered as fair examples of simple apoplexy in its idiopathic form ; I add the following examples of the affection supervening upon other diseases. Case XCV.—A lady, aged 50, had been liable for many years to attacks of cough and dyspnoea, which were generally relieved by opiates and blistering. On the 20th of Decem- ber, 1816, she was seized with one of these attacks in the or- dinary form. On the 22d she was better, though her breathing was still considerably oppressed. On the morning of the 23d she complained of headach, and wished not to be disturbed. Soon after this she appeared to her family to fall into a sound sleep; but some time after, it was found to be perfect apo- plexy, from which nothing could rouse her, and she died about five o'clock in the afternoon. I saw her only an hour before her death; she was then in perfect coma, her lips livid, her 228 SIMPLE APOPLEXY. breathing quick and oppressed, and her pulse frequent and feeble. Inspection.—On the surface of the brain the veins were turgid, and the substance, when cut into, exhibited a remark- able degree of vascularity; there was no other appearance of disease* The lungs were distended, and much loaded with thin mucus, but their structure was tolerably healthy. The other viscera were sound. Case XCVI.—A lady aged 45, had for three months be- fore her death been affected with the following symptoms:— nausea, and a peculiar uneasy feeling about the stomach, par- ticularly after meals; a feeling of distention of the abdomen, costiveness of the bowels, and anasarca of the feet and legs. The appetite was tolerable, and the pulse natural, but from being remarkably strong and active, she became feeble, sal- low, inactive, and listless. A variety of practice was employed for three months with little benefit; the anasarca gradually extended; effusion took place in the abdomen, and there was much reason to suspect that it had also taken place in the thorax ; the pulse, however, continued of natural frequency and good strength. On the evening of the 18th of May, 1816, she was observed to talk hurriedly and incoherently. On the morning of the 19th, she was in a state of stupor, from which at first she could be partially roused ; but soon after mid-day it increased to perfect coma. She then lay in a state of per- fect apoplexy, with stertorous breathing and much moaning, the face rather pale, the pulse 72 and of good strength, and she died on the morning of the 20th. The catamenia had been regular, except at the last period, which should have happened about the 12th of May. Inspection.—No disease could be detected in the head after the most careful examination. There was considerable effusion both in the thorax and the abdomen. In the heart there was considerable hardness about the root of the tricus- pid valves. No morbid appearance could be discovered in the other viscera. SIMPLE APOPLEXY. 229 I have already referred to various cases mentioned by the older writers, in which apoplexy was fatal, without leaving any morbid appearance; and others are related by later au- thors of undoubted authority. A man, mentioned by Dr. Stark,* after complaining of headach and giddiness, fell down in a state of insensibility, with some convulsion. He then lay in a state of profound apoplexy for forty-five hours, when he died. No morbid appearance could be discovered in the brain on the most careful examination. A young lady, mentioned by Dr. Powel, after appearing for one day very heavy and disposed to sleep, fell into a state of perfect coma, which was interrupted only by occasional at- tacks of general convulsion. Without any change in the symptoms, she died on the third day. After the most mi- nute examination, no morbid appearance could be discovered in the brain. Similar cases are related by other writers, and, upon the whole, I think we have sufficient ground for stating it as a fact, that there is a modification of apo- plexy which is fatal without leaving any morbid appearance that can be discovered in the brain. § II.—Apoplexy with serous effusion. Case XCVIL—A gentleman, aged 80, but vigorous and active, and of rather a spare habit, about the 9th of June, 1813, began to be affected with loss of recollection, indis- tinctness of speech, and flushing of the face. He appeared to have at times a weakness of the right arm, being observed occasionally to drop things from the right hand, but he did not admit that he felt any weakness of it. He complained neither of headach nor giddiness, but said he was weak, and did not feel himself right; the pulse was natural, and of good strength. After a bleeding from the arm, followed * Works of Dr. Wm. Stark, page 73. 30 230 APOPLEXY with SEROUS EFFUSION'. by purgatives and a regulated diet, he seemed to be much improved; he had in a great measure recovered his recol- lection, and had lost the flushing of his face, and his speech was much more distinct. He walked out regularly, and his step was firm and vigorous. Soon after, however, he began to have a recurrence of confusion of thought, particu- larly on the 27th, when in endeavouring to write a letter, he was obliged to relinquish the attempt. He complained that he could not make sense of it, nor spell the words; the writing was scarcely legible, and the lines were very crook- ed. On the 28th he seemed much better. On the follow- ing night he slept ill; got up about four o'clock in the morning, and said he felt restless and uneasy; he walked about his room for some time, and then returned to bed. Having soon after this become quiet, his family did not dis- turb him till between eight and nine o'clock, when he was found in a state of perfect apoplexy, his pulse 80 and full, the appearance of the countenance natural; he was inca- pable of swallowing, and in a state of complete insensi- bility, except that he occasionally moved his right hand. He was largely bled, after which he became exceedingly pale, and the pulse continued for a considerable time very weak, but without the smallest abatement of the coma. The other usual remedies were then employed without any be- nefit. In this state of perfect apoplexy he lay for seven days, during which time there was very little change in the symptoms. He frequently moved his right arm and leg, but not the left; he occasionally scratched a herpetic erup- tion which was on the thigh, and several times moved his night-cap. Once or twice he was observed to open his eyes slightly for a few seconds; the pupil was natural, and con- tracted when a candle was brought near it. He passed his urine in the bed. He never swallowed a drop of any thing. His pulse at first varied from 80 to 100, but afterwards rose to 120. In this state of perfect apoplexy he died on the fifth of February. A few days before his death, a glandular swell- APOPLEXY WITH SEROUS EFFUSION. 231 ing appeared on his neck, from which he evidently felt pain, as he drew away his head when it was touched. Inspection.—A good deal of fluid escaped when the cra- nium was opened; there was considerable effusion under the arachnoid, and in the ventricles; the quantity collected was probably from three to four ounces. No other morbid ap- pearance could be detected in any part of the brain. Case XCVIII.—A gentleman, aged 70, of a florid com- plexion, but rather infirm in his limbs, had suffered repeated attacks of loss of recollection, which were said by his family to resemble fainting fits. At the commencement of the illness of which he died, he fell down suddenly deprived of sense and motion. After some time he recovered from this state of perfect insensibility, but his speech was now inarticulate; he had lost the power of his limbs, and his right eye was distorted outward. He was then confined to bed; at times incoherent, at other times more distinct, but always much oppressed, bor- dering upon coma; his speech continued very inarticulate, and his pulse was generally about 100. His strength sunk gradually, without any particular change in the symptoms; and he died at the end of five weeks. Inspection.—The ventricles of the brain were found dis- tended with colourless fluid, and there was a considerable quantity under the arachnoid. There was no other morbid appearance. Case XC1X.—A man, aged 41, of a very full habit, had been for some time affected with cough, dyspnoea, and ana- sarca of the legs, when he became one day suddenly incohe- rent, and soon after fell into coma. His breathing was much oppressed; his face livid and turgid; the pulse somewhat fre- quent. The coma was of that kind out of which he could be roused with difficulty so as to answer questions slowly, and heavily, and often incoherently. He died on the third day. Inspection.—Much fluid was found in the ventricles of the 232 EXTENSIVE EFFUSION WITHOUT APOrLEX\. brain. The lungs were much loaded with blood, and there was considerable effusion in the cavity of the pleura. In the heart the foramen ovale was open, of the size of a goose quill. In concluding this part of the subject, I shall only add the following remarkable case, for which I am indebted to Mr. Turner, of extensive effusion in the cranium without any apoplectic symptom. Case C.—A gentleman, aged about 70, a man of talent and of genius, had been valetudinary and hypochondriacal for upwards of 30 years, having been affected with a variety of uneasy sensations in the stomach, as indigestion, a sense of tightness across the lower part of the abdomen, and occasion- ally attacks of dysuria. In the beginning of 1817, he became feeble, listless, and unable for any exertion either of body or mind; during the day he was drowsy, but his nights were restless and feverish. His countenance was pale and sallow; his pulse from 76 to 84; his tongue slightly loaded; his bowels generally costive, but easily moved by medicine, the opera- tion of which was sometimes followed by diarrhoea. A va- riety of remedies were employed without benefit. He passed the summer without improvement, and in the winter his com- plaints were aggravated. They consisted as formerly of hea- viness, feebleness, and want of sleep, to which were now add- ed a troublesome cough and constant pain in the lower part of the abdomen, with strangury. His appetite failed; his pulse increased in frequency; and he became daily more and more feeble and emaciated. In the beginning of March, 1818, he was confined to bed; his strength then sunk gradually, and he died on the 14th, having retained his memory and all his faculties entire till within a few hours of his death. He had never complained of headach or giddiness, and never had any paralytic or convulsive affection. Inspection.—A copious effusion of transparent fluid was EXTENSIVE EFFUSION WITHOUT APOPLEXY. 233 found over the whole surface of the brain under the arach- noid membrane, which, in various places, particularly at the posterior part, elevated that membrane in the form of small bladders, and separated some of the convolutions from each other, so as to form depressions on the surface of the brain. The ventricles were also distended with fluid, but not much enlarged. The brain was in other respects sound; the visce- ra of the abdomen were healthy. The bladder was contract- ed and thickened, but there appeared to be no disease of the prostate gland or the urethra. In the former part of this work, I have referred to several cases in which extensive effusion was found in the brain, with- out any apoplectic symptoms. The fluid in one of them amounted to eight ounces, and several other cases of the same kind are on record. Dr. Marshall mentions a maniac, who died of mortification of his feet; a few hours before death, he became perfectly rational, yet effusion was found both on the surface of the brain and in the ventricles, amounting to more than a pound. The apoplectic cases in which we find only serous effusion, constitute that modification of the disease which has been called serous apoplexy. In regard to this affection, or rather to this mode of expression, I submit the following observa- tions. I. The distinction which has been proposed betwixt san- guineous and serous apoplexy is not supported by observation. The former is said to be distinguished by flushing of the coun- tenance and strong pulse, and by occurring in persons in the vigour of life; the latter by paleness of the countenance and weakness of the pulse, and by affecting the aged and infirm; and much importance has been attached to this distinction, upon the ground, that the practice, which is proper and ne- cessary in the one case, would be improper or injurious in the other. I submit that this distinction is not founded upon ob- 234 OF THE TERM SEROUS APOPLEXY. servation; for, in point of fact, it will be found, that many of the cases which terminate by serous effusion, exhibit, in their early stages, all the symptoms which have been assigned to the sanguineous apoplexy; while many of the cases, which are accompanied by paleness of the countenance and feeble- ness of the pulse, will be found to be purely sanguineous; and one modification of the disease in particular will be described, in which these symptoms are very strikingly exhibited, while the disease is found to be sanguineous apoplexy in its most hopeless form. Portal has described a series of cases which afford the same result; of three, which presented all the symp- toms of serous apoplexy, one was saved by repeated bleeding, and in the other two which were fatal, there was found ex- tensive extravasation of blood. Case XCVI. lately described, forms a remarkable addition to these observations. If any case could be confidently considered as serous apoplexy, this was such. Dropsical effusion had existed in the body for months; and in defiance of every remedy, it had been progressively gaining ground. There were symptoms indicating its exist- ence both in the thorax and in the abdomen; the patient then became comatose, with pale countenance, and died; but though dropsy was found in the other cavities, none could be detect- ed in the brain. II. In other parts of the body, serous effusion is very sel- dom a primary disease; it arises as a result either of inflam- matory action, or of impeded circulation, and takes place slowly, not accumulating at once in such quantity as to in- duce urgent symptoms. It is, therefore, in the highest degree improbable, that it should occur in the brain as a primary dis- ease, and accumulate with such rapidity as to produce the symptoms of an apoplectic attack. III. The quantity of fluid effused bears no proportion to the degree of the apoplectic symptoms. We find it in small quan- tity though the apoplectic symptoms had been strongly marked and long continued; we find it in large quantity when the symptoms have been slight; and, finally, we find most exten- GENERAL CONCLUSIONS. 235 sive effusion in the brain where there have been no apoplec- tic symptoms at all. The direct inference from these facts is, that in the cases of apoplexy with effusion, the presence of the fluid cannot be considered as the cause of the apoplectic symptoms. The facts which have been related in this section appear to warrant the following conclusions. 1. There is a modification of apoplexy which is fatal, with- out leaving any morbid appearance that can be discovered in the brain. 2. There is another modification, in which we find serous effusion, often in small quantity. 3. The cases which are referrible to these two classes are not distinguished from each other, by any such diversity of symptoms as can be supposed to indicate any essential differ- ence in their nature. 4. Without any apoplectic symptoms, we find serous effu- sion in the brain in an equal or in a greater quantity than in the cases of the second modification. 5. It is therefore probable, that in these cases the effusion was not the cause of the apoplectic symptoms. 6. It is probable, that the cases of the first modification de- pend upon a cause which is entirely referrible to a derange- ment of the circulation in the brain distinct from inflamma- tion. 7. It is probable, that the cases of the second modification are, at their commencement, of the same nature with those of the first; and that the serous effusion is to be considered as the result of that peculiar derangement of the circulation, which constitutes the state of simple apoplexy. In other words, it is probable, that the affection which has been called serous apoplexy is to be considered as simple apoplexy termi- nating by effusion. 236 APOPLEXY WITH EXTRAVASATION. SECTION II. OF THE CASES OF THE SECOND CLASS NOT PRIMARILY AFOPLECTIC. The cases to be described under this section differ remark- ably from those which are properly styled apoplexy. They are not at first apoplectic; or if there be at the very first at- tack loss of sense and motion, this state is recovered from in a few minutes, or perhaps seconds, without any remedy. The prominent symptom, at the commencement of the disease, is a sudden attack of violent headach, the patient often starting up and screaming from the violence of it. Sometimes he falls down pale, faint and exhausted, often with slight convulsion, but recovers from this state in a very short time. In other cases he does not fall down, but feels a sudden and great un- easiness in his head, generally with paleness, sickness, and often vomiting. The first attack being so far recovered from that the patient is often able to walk home, the symptoms go on under various modifications. The fixed pain in the head generally continues, often referred to one side of the head; and generally there is vomiting. The patient continues for some time perhaps an hour or two, cold and feeble, with cadaverous paleness of the countenance; his pulse weak and generally frequent. He is quite sensible, but oppressed. By degrees he recovers heat and the natural appearance of the countenance, and the pulse improves in strength. The face then becomes flushed; he is more oppressed; he answers questions slowly and heavily; and at last sinks into coma, from which he never recovers. The period occupied by these changes varies exceedingly in different cases. In one case to be described, there intervened, from the first attack to the commencement of coma, 5 hours; in a second, 12 hours; in a third, 3 days; and in a fourth, not more than 15 or 20 APOPLEXY WITH EXTRAVASATION. 237 minutes. Death followed the appearance of coma in the first of these cases in 7 hours, in the second in 32 hours, and in the third in two days. Other varieties occur which will be exemplified by the cases. Sometimes the coma follows so speedily, that the case closely borders upon the attack of simple apoplexy. But I think there is almost always a cer- tain interval of sense, generally with violent complaint of pain, , and not that immediate and complete loss of sensibility which occurs in what may be strictly called the apoplectic attack. This modification will be exemplified in Case CXI. In Case CVI. again, after the first attack there was an interval of a fortnight, without any urgent symptom; the complaint then returned, and was speedily fatal. In Case CV1I. which seems to belong to this class, after the coma had continued three days, there was a complete recovery from it, succeeded by maniacal delirium. This, after seven days, was again follow- ed by coma, which in three days more was fatal. In Case CIV. there was also, after evacuations, a temporary recove- ry from the coma, about 12 hours after its appearance, and 20 hours before death. As far as my observation extends, the cases which belong to this class are generally fatal. They form a modification of the disease, remarkably different from the simple apo- plectic state; and on inspection, we find none of those va- rieties and ambiguities which occur in the apoplectic cases, but uniform and extensive extravasation of blood. From the whole history of them, I think there is every reason to believe, that they depend upon the immediate rupture of a considerable vessel, without any previous derangement of the circulation, the rupture probably arising from disease of the artery at the part which gives way. At the moment when the rupture occurs, there seems to be a temporary de- rangement of the functions of the brain, but this is soon re- covered from. The circulation then goes on without in- terruption; until such a quantity of blood has been extrava- sated as is sufficient to produce coma. In their whole pro- 31 238 APOPLEXY WITH EXTRAVASATION. gress, these cases are strictly analagous to those of extrava- sation on the surface of the brain, from external injuries. The patient recovers from the immediate effects of the inju- ry, walks home, and after some time, perhaps an hour or two, becomes oppressed and at last comatose. The extravasated blood being in this case removed by the operation of tre- phine, the coma disappears. The varieties of the symptoms which occur in this form of the disease, are such as we might expect upon this view of the nature of the affection. • In some cases it is probable that the extravasation goes on progressively, until such a quantity has been accumulated as is sufficient to produce the fatal coma. In others there is reason to believe that soon after the rupture has taken place, the haemorrhage is stopped by the formation of a coa- gulum, and after a considerable interval bursts out afresh and is fatal. This probably occurred in Cases CV. and CVI.; and in such cases, the two extravasations can sometimes on inspection be distinguished from each other by their appear- ance. In other cases, the second extravasation takes place in another part of the brain; and this probably occurred in Case CVII. In this case, the temporary recovery from the coma was remarkable—the apoplectic state having taken place two hours after the attack, and having continued for three days. At that time, it is probable, the evacuations employed had the effect of restoring the circulation, which then went on in a very imperfect manner, until it was a"-ain interrupted by the fresh extravasation. The rapidity with which the disease advances, in cases of this class, will of course depend in a great measure upon the size of the ves- sel from which the hasmorrage has taken place. In some cases, it will be seen to be very slow in its progress, and, in others, extremely rapid—a very short interval taking place betwixt the first attack and the occurrence of perfect coma, Even in some of these cases, however, the patient survives a considerable time; but in others the fatal event likewise takes place with very great rapidity. APOPLEXY WITH EXTRAVASATION. 239 The following selection of cases will illustrate the prin- cipal varieties of this very interesting modification of the disease. § I.—The coma rapidly supervening on the first ATTACK. Case CI.—A clergyman, aged 55, while delivering his sermon during the morning service of Sunday, 13th May, 1827, was observed to stop and put his hand to his head; he then attempted to go on, but talked indistinctly; and had evidently lost his recollection; he supported himself by grasping the side of the pulpit. Assistance being imme- diately given him, he was taken out, and at this time was speechless and paralytic of the right side, but appeared to be sensible. He became rapidly more and more oppressed, and, in about twenty minutes from the commencement of the attack, had become entirely comatose. From the time when he was taken down from the pulpit, he was pale and cold, and his pulse extremely feeble; and this state continued when I saw him about an hour after the attack; so that, though a vein was opened, very little blood could be obtained. Gradually the circulation rallied, and in another hour, a full bleeding was obtained without any relief. All the other usual reme- dies were employed without benefit. From the time when the coma took place, there never was the slightest abatement of it; he lay with his eyes shut, his countenance pale and sal- low, but placid and without distortion,—his pulse weak, the power of swallowing lost, the breathing at first stertorous, af- terwards slow and oppressed. He lived in this state till Monday at mid-day, about twenty-four hours after the at- tack. Inspection.—There was extensive extravasation of blood in the left ventricle, v." Vn had passed partly into the right by laceration of the septum. * It seemed to have made its way into the ventricle from the substance of the brain on the outer 240 APOFLEXY with extravasation. and anterior part, where there was a large irregular lacerated cavity, full of coagulated blood, and communicating with the ventricle; all the arteries of the brain were extensively ossi- fied. Case CIL—A man, aged 32, of a very full habit, while sitting by the fire on the evening of the 3d September, 1804, was suddenly seized with violent headach, followed by vo- miting. After a few minutes he began to talk incoherently, and soon after fell down in a state of insensibility, accompa- nied by a slight convulsion. His face was extremely pale, his body cold, and his pulse scarcely to be felt. From this state, which resembled syncope, he passed gradually into the appearance of apoplexy; and three hours after the attack, his breathing was stertorous, the body of natural heat, the pulse 72, and of good strength. The face was still pale, he had frequent vomiting, and was incapable of swallowing, and there had been no diminution of the coma. He now lay in a state of profound coma, and died 29 hours after the at- tack, without any change in the symptoms, except that, during the last 12 hours, the pulse varied from 100 to 120. Large blood-letting and the other usual remedies had been employed without the least benefit. Inspection.—All the ventricles of the brain were found distended with coagulated blood, which appeared to have burst into them from an irregular lacerated opening in the substance of the brain. § II.—An interval of perfect recollection for seve- ral HOURS BETWEEN THE ATTACK AND THE OCCURRENCE OF COMA. Case CIII.—A gentleman, aged 46, of short stature, full flabby habit, and sallow complexion, a literary man, and very sedentary, while speaking in a public meeting on the 28th April, 1807, was seized with an uneasy sensation in APOPLEXY WITH EXTRAVASATION. 241 his head, "as if his head would have burst," or "as if the brain had been too big for the skull." This feeling soon went off, and he continued his speech; but when he had finished it he left the room, and felt himself extremely un- well. He had cold shivering, nausea, and repeated vomit- ing; complained of headach and faintness; his face was pale, and his pulse feeble. After some time he was able to walk home, where I saw him at nine P. M. an hour or more af- ter the attack. He then complained of violent pain in the right side of his head, which came on in paroxysms, and, in the intervals, he was much easier; he had nausea and re- peated vomiting; he felt himself cold and faint; his face was pale and sallow; his pulse weak and rather frequent; he was quite sensible, but much oppressed, and answered questions very slowly. He was immediately bled from the arm, and, the pulse improving under the bleeding, it was continued to about 30 ounces, but without relief. He became gradu- ally more and more oppressed, and by 11 P. M. had sunk into coma, with stertorous breathing, and complete insen- sibility. In this state he continued till six o'clock on the following morning, when he died. More blood had been taken from the temporal artery, and the other usual reme- dies employed without the smallest benefit. During the last six hours of his life, the pulse varied exceedingly, be- ing sometimes slow and oppressed, sometimes frequent and full, and the transitions from the one state to the other be- ing very sudden; a short time before death it was strong and frequent. The pupil of the eye had retained its natu- ral appearance, and no paralytic symptom was observed in any period of the attack. Inspection.—A large quantity of coagulated blood was found spread over the surface of the brain, under the dura mater, in all directions, chiefly on the right side. The ori- gin of it was evidently from the substance of the right he- misphere, from which it had burst outwards by a large rag- ged opening. This opening communicated with a cavity 242 APOPLEXY WITH EXTRAVASATION. in the substance of the hemisphere, which also was full of coagulated blood. Large coagula were likewise found un- der the base of the brain, around the cerebellum, and about the upper part of the spinal cord. In the ventricles there was about an ounce of serous fluid. Case CIV.—A lady, aged 70, healthy and active for her years, had complained for a day or two of headach, but with- out being confined, or her health otherwise affected, till the evening of the 7th August, 1816, when she suddenly screamed out from violent headach, vomited, and then fell down in a state resembling syncope; her face was extremely pale, and her pulse scarcely to be felt; and there was some slight ap- pearance of convulsion. She recovered in a few minutes, and went to bed. Through the night she was restless, vo- mited repeatedly, and three or four times fell into a kind of fainting fit, of a few minutes' duration. In some of these she was reported to have made a gurgling noise in her throat, and to have shown some convulsive motions of the arms: in the intervals she was quite sensible, and complained of headach. About eight o'clock in the morning of the eighth, she sunk into coma. I saw her for the first time about ten; she was then completely comatose; breathing stertorous; face rather pale; pupil contracted; pulse of good strength, and a little frequent. The usual remedies were employed, and in the evening she had so far recovered, that, when raised up in bed, she took into her hand a glass containing some purgative medicine, and drank it. She seemed to at- tempt to speak, but could not; and soon after relapsed into perfect coma; pulse at night 112; there seemed to be no pa- ralysis. (9th,) continued in perfect coma, and died at four in the afternoon. Inspection.—In the anterior lobe of the right hemisphere of the brain, there was a cavity containing a mass of coagu- lated blood the size of a small hen's egg. From this cavi- ty the blood had forced a passage through the substance of APOPLEXY WITH EXTRAVASATION. 243 the brain downwards, and had spread in all directions un- der the base of the brain, and upwards on both sides, be- twixt the dura mater and the arachnoid, to such an extent, that portions of it were found on the upper surface of the brain on both sides of the falx. The substance of the brain surrounding the cavity was soft and much broken down. There was nothing in the ventricles, and all the blood-ves- sels appeared remarkably empty. § III.—An interval of three days between the at- tack AND THE OCCURRENCE OF COMA. Case CV.—A gentleman, aged 18, previously in good health, after using rather violent exercise in the forenoon, had returned home before dinner, and was sitting near the fire, when, without any warning, he started up, pushed his chair backwards with violence, exclaimed, "Oh, my head!" and instantly fell on the floor insensible, and slightly con- vulsed. I saw him within ten or fifteen minutes after the attack. By that time he had recovered his recollection, was sitting on a chair, and was quite distinct. His face was extremely pale, and his whole body cold and shivering: he complained of severe headach, and his pulse was weak and rather frequent. Blood-letting was immediately employed, and his pulse improved under it. It was repeated after a few hours, with the addition of purgatives, and the other usual remedies. The coldness and paleness went off after some time, and he then complained only of severe headach, with a feeling of stiffness of his neck, and pain extending downwards along the cervical vertebras; his pulse was rather frequent and of good strength. He continued in this state for two days, the headach varying very much in degree, and fre- quently complained chiefly of his neck; his pulse was fre- quent, 120 or more, and of good strength; the other functions were natural; he was quite distinct; had the use of all his limbs, and could get out of bed with little assistance, and sit 244 APOPLEXY WITH EXTRAVASATION. up a considerable time. On the third day he began to be more oppressed, and a little confused and forgetful; the other symptoms as before. On the fourth he sunk very gradually into coma, and died on the 5th. His pulse had continued from 120 to 140; there had been no paralytic symptom; hut, on the fifth day, there was repeated convulsion. Blood-let- ting and all the other usual remedies had been employed with- out benefit. Inspection.—All the ventricles of the brain were complete- ly filled with coagulated blood. In the substance of the left hemisphere there was a cavity formed by laceration of the cerebral substance, filled also by the coagulum, and commu- nicating with the ventricle. There was no other morbid ap- pearance. § IV.--THE FATAL COMA OCCURRING A FORTNIGHT AFTER THE FIRST ATTACK. Case CVI.—A lady, aged 56, enjoying good health, except occasional disorders in the stomach, on Tuesday, the 30th July, 1816, walked out in perfect health; had gone but a very short distance, when she was seized with violent pain in the head and giddiness; soon after, she lost her recollection and fell down. She very soon recovered her recollection, and was carried home, being unable to stand. She was then seen by Mr. White, who found her pale and faint; the pulse 70 and weak. She was a little incoherent, complained of severe headach, and had repeated vomiting. The vomiting recur- red frequently for two days, and then subsided; the severe headach continued a week. During this period, she was ge- nerally confined to bed, but was sometimes able to sit up for a short time; her face was pale; her pulse from 70 to 76, and rather weak; she had some appetite, but bad sleep. She had no paralytic symptom, and made no complaint except of con- stant pain of her head, which was always referred to the back part. At the end of the week, this pain became much less APOPLEXY WITH EXTRAVASATION. 245 severe; she then complained chiefly of pain in the back and limbs, and some dysuria; her pulse was as formerly, and her mind entire. In this manner she passed another week, still confined to bed, but towards the end of the week, she ap- peared to be much better. On Tuesday, 13th August, exact- ly a fortnight from the first attack, she was suddenly seized with violent pain in the head, chiefly referred to the back part of it; in less than an hour she became comatose; and in three hours more was dead. The face had continued pale, and the pulse natural. I did not see this patient during her life, but was present at the examination of the body. Inspection.—In the substance of the anterior lobe of the right hemisphere of the brain, there was a cavity filled by a coagulum of blood, the size of a hen's egg. From this cavity a lacerated opening led into the right ventricle, and all the ventricles were completely filled by coagulated blood. A thin stratum of blood was also found under the base of the brain, which seemed to have escaped from the ventricles, by forcing a passage under the posterior pillars of the fornix. Around the cavity in the right hemisphere, the substance of the brain was much softened and broken down. Both the kidneys were unusually vascular ; about the right there was a remarkable tumescence of veins, and an appearance of ex- travasated blood in the cellular membrane behind it. § V.—TWO DISTINCT EXTRAVASATIONS. Case CVIL—A lady aged 40, of a spare habit, on the 15th May, 1811, at two o'clock P. M., was suddenly seized with headach, accompanied by vomiting and diarrhoea: and at the same time began to talk incoherently. She continued to talk incoherently for two hours, and then sunk into coma. I saw her at five; she was then in a state of perfect coma; face pale; the skin rather cold; the breathing soft and natural; the pulse 65, soft and rather weak. During the afternoon, she had 32 246 APOPLEXY WITH EXTRAVASATION. frequent vomiting and repeated diarrhoea; no other change took place in the symptoms. Full bleeding was employed, and a blister on the head ; but she was incapable of swallow- ing. (16th, 17th, and 18th,) She continued in a state of per- fect coma; never opened her eyes, nor showed the least sen- sibility, except that she drew away her arm with violence when she was bled. She frequently moved all her limbs, and occasionally turned in bed. The pupil contracted a little when a candle was brought near it; the face was sometimes a little flushed, but generally pale. The pulse was from 70 to 80, and of good strength. There had been no return of the vomiting or diarrhoea after the 15th. Bleedings, both gene- ral and topical, were employed, with purgatives, &c. On the evening of the 18th, she came out of the coma rather sud- denly, like a person awaking from sleep; looked around her, put out her tongue when desired, and took what was offered to her; she also talked a little, but incoherently. (19th and 20th,) Much incoherent talking; appeared at times to under- stand what was said to her, but could give no account of her feelings, only said, "she was very bad;" pulse from 70 to 80. (21st, 22d,) Incessant talking and delirium ; at times unmana- geable and attempting to get out of bed; at these times the face was flushed, at other times it was pale; pulse varying from 90 to 120, weak and irregular; appeared to be blind, but had the use of all her limbs. (23d,) Highly delirious and ma- niacal. (24th, 25th,) Became calm and manageable, and at times very weak. Pulse small and feeble, skin cold with a clammy sweat; appeared at times to see and to know those about her. (26th,) Relapsed into coma; lay with her eyelids half shut, and the eyes distorted outwards: pulse from 80 to 100, and rather weak; face pale, was incapable of swallowing. Continued in a state of perfect coma on the 27th and 28th, and died in the afternoon of the 29th ;—the pulse had con- tinued about 90. Inspection.—All the ventricles of the brain were full of a dark-coloured fluid like coffee. In the substance of the APOPLEXY WITH EXTRAVASATION. 247 right hemisphere, there was a cavity containing a coagulum of blood, the size of a hen's egg. This cavity communicated with the ventricle, and the substance of the brain immediate- ly surrounding the cavity was very soft and much broken down. In the left hemisphere, at its upper and posterior part, there was a cavity the size of a large walnut. It con- tained a dark-coloured matter which appeared to be coagu- lated blood, but considerably changed in its appearance, be- ing firmer in its texture than recent blood, and of a brownish colour mixed with portions of a lighter colour, which appeared to be diseased cerebral substance. The substance of the brain surrounding this cavity was much softened and broken down. Some part within the substance of the hemispheres, as in these examples, seems to be the most common origin of the haemorrhage in cases of this class. It is, however, some- times found in the ventricles only, though more rarely. In the following case it was confined to the third and fourth ven- tricles. § VI.__The extravasation confined to the third and FOURTH VENTRICLES, WITH REMARKABLE DISEASE OF THE ARTERIES OF THE BRAIN. Case CVIII.—A gentleman, aged 55, of a thin spare habit, had, about six months before his death, an attack of hemiple- gia, which, after the usual treatment, subsided gradually. On the 10th October, 1819, he complained suddenly after dinner of giddiness and sickness; he went into another room, where he was found a few minutes after, supporting himself by a bed post; he was then confused and pale. Being put to bed, he soon became partially comatose, with muttering and frequent attempts to speak. I saw him more than an hour after the attack. He was then pale and sallow, pulse soft, languid, and rather slow. His eyes were open, but he did not seem to 248 APOPLEXY WITH EXTRAVASATION. comprehend what was said to him. A vein was opened, which bled very little, the circulation appearing extremely languid. Sometime after, he was bled again by Dr. Aitkin, when the blood flowed more freely, but without relief. He became completely comatose, and died about three o'clock • in the morning. Inspection.—In the lateral ventricles there was a consi- derable quantity of bloody serum; the third and fourth ven- tricles were full of coagulated blood. The arteries of the brain were in a great many places in a remarkably diseased state, being extensively ossified; and there was in many places a singularly diseased state of the inner coat of the artery. It was much thickened, and of a soft pulpy consistence; and large portions of it could be squeezed out when a piece of the artery was compressed between the fingers. In the cases now described, the haemorrhage appears to have taken place from the deep-seated arteries of the brain. In the two following cases, for which I am indebted to Dr. Barlow of Bath, and Dr. Hunter of this place, it appears to have been from the superficial vessels. § VII.—Extravasation on the surface of the brain. Case CIX.—A gentleman, about 63 years of age, tall and slender, and of temperate habits, was seized with apoplexy on the morning of the 2d of May, 1822. He was promptly re- lieved by bleeding, continued well through the day, and, on the morning of the 3d, appeared free from complaint. About two o'clock, however, there was a return of the attack, when he was again bled copiously, but without the effect of restoring consciousness. He was now seen by Dr. Barlow, and all the usual remedies were employed in the most active manner without relief. On the 4th, he was still comatose, and con- tinued so till ten o'clock at night, when consciousness re- turned, but continued only for a very short time. On the 5th, APOPLEXY WITH EXTRAVASATION. 249 he had an interval of recollection which lasted three hours; and he was again sensible for about a quarter of an hour in the evening. He had a similar interval for about an hour and a half on the 6th, but on the 7th was comatose nearly the whole day. On the 8th, there was a slight return of con- sciousness in the morning; and towards the evening, he was sensible for several hours. During these changes, the bow- els had been fully opened, the pulse had continued about 72 and soft, and no paralysis of any limb had been observed. On the 9th, he was still lethargic, with some stertor; but after to- pical bleeding and the operation of a purgative, he was much relieved; passed a quiet night, and on the morning of the 10th, v he was quite sensible. It was now first observed that he had lost the sight of the right eye, which was distorted outwards. On the 11th, he lay with his eyes shut, but took food, and answered questions intelligibly when he was spoken to. On the 12th, he was lethargic, but capable of answering, questions when he was roused; and this state continued on the 13th. On the afternoon of that day, there was an increase of stupor, with difficulty of swallowing. He was again partially relieved by leeches, a purgative, and a blister to the neck, but the re- lief was only temporary. He became gradually more coma- tose, and died early on the 16th. Inspection.—A copious extravasation of blood was found- extended over the surface of the brain; it was closely adherent to the dura mater, and could be peeled off like a membrane. The substance of the brain was healthy. There was no ef- fusion in the ventricles. In the communication with which Dr. Barlow has favoured me in regard to this singular case, he remarks, "the frequent returns of consciousness seemed to warrant a hope that no ir- remediable extravasation had taken place; yet the event proved that extensive sanguineous effusion had existed throughout. Was the lethargy owing to the extravasation?—and if so, why, under a permanently existing cause, was the effect so varia- 250 APOPLEXY WITH EXTRAVASATION. ble?" These interesting queries I do not at present attempt to answer. Case CX.—A man, aged about 35, keeper of a tavern, and addicted to the constant use of ardent spirits, had been drink- ing to intoxication during the night betwixt the 12th and 13th July, 1816; and, about seven o'clock in the morning, was found lying in a state of violent convulsion. No account could be obtained of his previous state, except that, during the evening he had drunk a very large quantity of whiskey, and that, when he was last seen about three o'clock in the morning, he was walking about his house, but unable to speak. He was seen by Dr. Hunter, at a quarter before eight. He was then lying on his left side, in a state of perfect insensibi- lity, with laborious breathing; saliva was flowing from his mouth; his eyes were much suffused, and greatly distorted,— the cornea of both being completely concealed below the up- per eyelid; pulse 120, full and soft. While Dr. Hunter stood by him, he was again seized with convulsion; it began in the muscles of the jaw, which was drawn from side to side with great violence, producing a loud jarring sound from the grind- ing of the teeth. The spasms then extended to the body and extremities, which were first thrown into a state of violent extension and then convulsed for one or two minutes; they then subsided, and left him as before in a state of perfect in- sensibility. Similar attacks took place four times while Dr. Hunter remained in the house, which was about half an hour; and he expired in another attack of the same kind about ten minutes after. Blood-letting, and every other remedy that the time admitted of, were employed in the most judicious manner. Inspection.—On removing the skull-cap, an appearance was observed on the surface of the dura mater, of coagulated blood in small detached portions. These appeared to have been discharged from small glandular-looking elevations on the outer surface of the dura mater, which were very vascular, APOPLEXY WITH EXTRAVASATION. 251 and highly gorged with blood. There were depressions on the inner surface of the bone, which corresponded with these bodies. On raising the dura mater, there came into view a coagulum of blood, covering and completely cor cealing the right hemisphere of the brain; it was about two lines in thick- ness over the middle lobe, and became gradually thinner as it spread over the anterior and posterior lobes, and dipped down below the base of the brain. The coagulum being re- moved, measured about |v. On the surface of the left he- misphere, the veins were turgid with blood; on the surface of the right they were entirely empty; but the source of the hae- morrhage could not be discovered. There was no fluid in the ventricles, and no other disease was discovered. The Stomach being carefully examined, was found to contain no- thing but air and some healthy mucus. The following case, for which I am indebted to Dr. Ma- cauley, is altogether a remarkable one. It is the most rapidly fatal case of cerebral disease that has occurred to me. Case CXI.—A woman, aged 54, who had been for several years liable to headach, attended a crowded meeting on the evening of 25th June, 1829, and seemed in perfect health. Towards the conclusion of the meeting she uttered a loud and convulsive scream, and instantly fell down in a state of insen- sibility. She was immediately carried out, and was seen by Dr. Macauley, who happened to be present: he found her pale and totally insensible, and the pulse feeble; and within five minutes from the first seizure she was dead. Inspection.—The integuments of the head were much loaded with blood. On removing the dura mater, there was a thin but very extensive appearance of extravasated blood, or rather ecchymosis, which covered nearly the whole surface of the brain. In the substance of the anterior lobe of the right hemisphere there was a coagulum of blood the size of a 252 APOPLEXY WITH EXTRAVASATION. large bean. All the other viscera were examined in the most accurate manner, but nothing was discovered except a tubercle on the liver, and a small spot of ossification on the the abdominal aorta. When the disease takes place in the cerebellum, or below it, the symptoms appear to be more rapid in their progress than when it is in the substance of the "brain: the two fol- lowing cases will illustrate this modification of the disease; for the second of them I am indebted to the late Dr. Hennen. § VIII.—Extravasation in the cerebellum. Case CXII.—A woman, aged about 70, a midwife, of a full habit and short stature, while sitting by the bed of a lady whom she was attending, suddenly exclaimed, " I am gone!" and almost immediately fell down in a state of coma, with some vomiting. She lay in a comatose state, without any change in the symptoms for 40 hours, and then died. Inspection.—A coagulum of blood, the size of a pigeon's egg, was found in the right lobe of the cerebellum. There was no other morbid appearance. Case CXIII.—A private in the 10th Hussars, of a spare habit, about a month before his death was attacked with a pain in the back of his head, for which a blister was applied, and the pain soon went off. On the 22d July, 1819, he was seized with giddiness and fell down: on being raised, he vomited and complained of violent headach and faint- ness, but was quite sensible; he was very pale, and his pulse was slow and languid. Being carried to the hospital, he continued in the same state; asked for cold water, which he swallowed, and seemed relieved of the faintness, but continued very pale. In a few minutes his eyes became fixed; he drew deep inspirations, and in two minutes more APOPLEXY WITH EXTRAVASATION. 253 was dead. From the moment of seizure, he did not move either the upper or lower extremities. Inspection.—Nothing unusual was discovered in the brain. On^raising the tentorium, the vessels of the cerebellum ap- peared very turgid. On removing the cerebellum, a coagu- lum of blood of about two ounces was found under it, and surrounding the foramen magnum. § IX.—Extravasation in the substance of the tuber ANNULARE. Case CX1V.—A gentleman, aged 37, had been for several months in bad health, being affected with occasional tightness of the chest and difficulty of breathing. He had also severe dyspeptic complaints, with occasional vomiting, a yellow tinge of his skin, and considerable uneasiness in the region of the liver. For these complaints he had been advised by his me- dical attendants in the north, to go to Cheltenham, and arrived in Edinburgh with that intention on 22d March, 1828. I saw him on the following day along with Mr. Wishart. We found his pulse frequent, his countenance sallow, and his expression febrile and anxious. He complained chiefly of tightness across his chest, with some pain in the region of the liver. Respi- ration was very imperfect along the right side of the thorax, and there was some oedema of the legs. By topical bleeding, purging, &c. he was considerably relieved; and on the 24th he expressed himself as feeling much better, but his pulse continued frequent. On the morning of the 25th he was sud- denly seized with giddiness, noise and confusion in his head, and numbness of the whole right side. He was oppressed, but not comatose; answered questions distinctly, but in a loud voice, and with a peculiar manner. He complained chiefly of noise in his head, of a tight and cramped feeling of his right arm and leg, with much prickling and loss of command 254 apoplexy with extravasation. of the parts, but when desired to grasp another person's hand with his, the muscular power did not seem to be diminished. The expression of his countenance was vacant and fatuous: t he eye was natural. The face was slightly distorted, and the speech was in some degree embarrassed. The pulse was 120. After large blood-letting and the other usual remedies, the symptoms gradually assumed a more favourable aspect, and after four or five days, he was considered as being out of any immediate danger, though the effects of the attack were by no means removed. His pulse was now natural, his speech was distinct, and his mind entire; his sight was good, and the appearance of the eye natural, except a slight degree of para- lysis of the upper eyelid of the right side. His breathing was easy, and he made no complaint, except of the tight and cramped feeling with numbness of the right arm and leg. His look however continued vacant and peculiar. His appetite and digestion were good, and his bowels easily regulated. He was improving in strength, and was able to be out of bed part of the day. This favourable state continued till the 14th of April, on which day he was found with a very frequent pulse without any other change in the symptoms. This febrile state continued on the two following days with rapid failure of strength, and he died on the evening of the 16th. He continued sensible to the last, and during this febrile attack, he seemed to have acquired an increased command over the l.mbs of the affected side. About the commencement of his illness of 25th March, he complained of considerable un- easiness in passing his urine; for a day or two it was bloody and there was a good deal of tenderness in the region of the bladder. After a few days this subsided, and he began to pass considerable quantities of puriform fluid of remarkable fetor, which subsided to the bottom of the chamberpot, after he urine had stood for a short time. This continued during he remainder of his life, though it had greatly diminished m quantity for several days preceding the last febrile attack. APOPLEXY WITH EXTRAVASATION. 255 The urine was in sufficient quantity, and passed without diffi- culty. Inspection.—The brain and cerebellum were found in every respect in the most healthy state, and no vestige of disease was discovered until the cerebellum was separated from the tuber annulare. In doing so a cavity was exposed about the size of a large hazel nut, lined by a soft cyst, and full of dark grumous blood of a firm consistence. This re- markable cavity was formed partly in the substance of the tuber, and partly betwixt it and the base of the cerebellum. It was decidedly more to the left side than the right, and the surrounding substance was softened, and tinged with dark red points, as if from injection of dark blood. There was effusion in the thorax to the amount of at least lb. ii. The right lung was contracted, and extensively hepatised; the left was much loaded with sero-purulent fluid. The liver was very considerably enlarged, and of a pale-ash colour and granular texture. The left kidney was pale, indurated, and tubercular. The inner surface of the bladder was deeply in- jected, and in several places showed distinct round ulcers about a quarter of an inch in diameter. § X.—Extravasation in all the ventricles, and along the whole course of the spinal cord. I conclude this part of the subject with the following case, showing the most extensive extravasation of blood that has ever occurred to me. The case is also remarkable from the period of life at which the affection took place, and its similarity in the symptoms to one of the common inflam- matory affections terminating by effusion. Case CXV.—A boy, aged nine, previously in perfect health, awoke in the night of lSth May, 1829, complaining of headach; had vomiting and slight convulsion. On the 256 APOPLEXY with extravasation. 19th, he was seen by Mr. W. Brown, who found him still complaining of headach with occasional vomiting, but with- out any urgent symptom. Under the usual treatment the complaint seemed gradually to subside, and on the 25th he appeared to be entirely recovered. But on the afternoon of that day, he had a return of convulsion, and in the eve- ning complained much of headach. Pulse 64.—26th and 27th, said he was better, but seemed drowsy. Pulse slow. Bowels obstinate.—28th, had two attacks of convulsion, the second of which was very severe and continued for se- veral hours, affecting chiefly the left side of the body. Pulse 130. On the 29th he was again better; but from this time he became gradually more and more drowsy, and at last comatose with squinting, and occasional convulsive mo- tions of the limbs, and he died on the 3d of June. His death was preceded by severe convulsion of several hours' duration. I saw him along with Mr. Brown from the 29th. Inspection.—The surface of the brain was healthy. The lateral ventricles were distended with dark bloody fluid, and each of them contained a mass of coagulated blood; that in the right was the size of a large walnut, the other small- er. The 3d and 4th ventricles were quite filled with coa- gulated blood in a very firm state, and from the bottom of the fourth ventricle, the coagulum was traced outwards and spread along the base of the brain and cerebellum, and around the medulla oblongata. The spinal canal being now laid open, the dura mater of the cord appeared remarkably distended, and the cord was found through its whole extent entirely enveloped by a very firm and uniform stratum of coagulated blood. The brain and cord were in their sub- stance healthy, and the source of the haemorrhage could not be discovered. The source of the haemorrhage in cases of extravasation in the head appears to be exceedingly various. I. The most common is probably the rupture of a vessel apoplexy with extravasation. 257 of moderate size in the substance of the brain, from which the blood bursts by laceration either into the ventricles, or to the surface, or in both these directions at once, as in a case described by Morgagni. It is in vain in general to at- tempt tracing it to particular vessels; Dr. Cheyne was able to do so in some instances; but, in general, numerous ves- sels must be laid open by the extensive laceration, and hence probably the appearance which has been observed, as if the extravasation had taken place from various points at once. A case is described by Serres in which the rupture took place in the substance of the pons Varolii; and from this the blood had burst forth into the occipital fossa. * II. The superficial vessels. This probably took place in the remarkable cases communicated by Dr. Hunter and Dr. Barlow. This appears to be the meningeal apoplexy of Serres. The blood seems in general to be accumulated be- twixt the dura mater and the arachnoid; but cases have been described by Fernelius and Tulpius, in which the blood ap- peared to be confined beneath the pia mater, and to have been discharged from the retiform plexus of vessels at the base of the brain. III. From ulceration and rupture of one of the principal arterial trunks. Dr. Mills has described a case in which the haemorrhage was distinctly traced to ulceration and rupture of the basilar artery; and a similar affection of the internal carotid is described by Morgagni and by Serres. IV. From the vessels of the choroid plexus, as in a case described by De Haen. This may probably be the source of haemorrhage in those cases in which it is confined to the ventricle, without any laceration of the substance of the brain. In Case CVIII. it was confined to the third and fourth ventricles. V. Rupture of one of the sinuses, as in a case described * Annuaire Med. Chirurg. 258 apoplexy with extravasation. by Dr. Douglas,* in which the left lateral sinus was rup- tured. VI. From the rupture of small aneurisms in various parts of the cerebral vessels. In a case by Serres, such an aneu- rism occurred in the basilar artery, which, when it was dis- tended, was as large as a small hen's egg. A pound of blood had been discharged by the rupture of it. This man had been long subject to a feeling of weight in the head, and, according to his own statement, to an indescribable stupidity, which was much increased by bodily exertion, and by strong liquors. In the Archives Generates de Me- dicine, a case is described, in which apoplexy followed the bursting of a small aneurism in the circle of Willis. VII. In the Medical and Surgical Register of the Hos- pital of New York, a very uncommon case is described by Dr. Watts, in which the haemorrhage took place betwixt the dura mater and the bone, from erosion of a vessel in connexion with caries of the inner surface of the parietal bone of the left side. The man was suddenly seized with hemiplegia of the right side, and died in five days. The carious spot on the inner surface of the bone was not so large as a sixpence. In the most common form of this affection, in which the haemorrhage proceeds from a vessel in the substance of the brain, I have supposed the rupture to take place from dis- ease of the artery itself, without any relation to that con- gestive or hemorrhagic condition which seems to constitute the state of simple apoplexy. Such disease, accordingly, will be very generally found to exist in cases of this class. It consists in some instances of ossification of the arteries in various places, and in others, of that peculiar earthy brit- tleness, which Scarpa has described as leading to aneurism; * Edin. Med. Essays and Observ. vol. vi. apoplexy with extravasation. 259 and the canal of the artery will be found in many places to be considerably narrowed or contracted at the hardened parts, and sometimes entirely obliterated. In other cases again, numerous branches of the principal arteries of the brain will be found to present a succession of small opaque osseous rings, separated from one another by small portions of the artery in a healthy state. This is a very common appearance in the brains of elderly people, and the rings are generally from half a line to a line in breadth, and are separated from each other by healthy portions of about the same extent. In some cases again the inner coat of the ar- tery is much thickened, of a soft pulpy consistence, and very easily separated; so that, when a portion of the artery is compressed between the fingers, a considerable quantity of this pulpy matter is forced out. This was very remark- able in Case CVIII. In a cale of apoplexy very rapidly fatal, which occurred to Dr. Duncan, junior, and Mr. Wish- art, they took particular notice of the remarkably diseased state of the arteries of the brain, which they describe as ex- hibiting every where the "earthy brittleness of Scarpa." There is much reason to believe, that this diseased condition of the arteries of the brain may give rise to a variety of com- plaints in the head; and that, after going on for a considera- ble time in this manner, it may at length be fatal by rupture. This appears to be probable from the history of many cases. I shall only give the following as an example. Case CXVI.—A gentleman, aged about 50, was for several years affected with complaints in his head, which assumed a great variety of characters. He had at first attacks of gid- diness and headach, with loss of recollection and impaired speech. These occurred from time to time, and went off without leaving any bad consequences. After a year or two the symptoms became more permanent, and he had violent paroxysms of pain, which at one time were much relieved by arsenic. He then had attacks bordering upon mania, 260 apoplexy with extravasation. with loss of recollection for several days. Afterwards he had epileptic attacks, alternating with these maniacal paroxysms. He next was affected with attacks of stupor of various dura- tion. The disease went on in this way for several years; and he died at last in May, 1820, after an apoplectic attack which continued eight or nine days. Inspection.—Connected with the fatal attack, there was a coagulum of blood, the size of an egg, in the substance of the right hemisphere. The only other morbid appearance was a remarkably diseased state of the whole arterial system of the brain. It was most extensively ossified, with a thick- ened and very diseased state of the inner coat of the arteries, and partial separation of it from the other coats in many places. Scarcely any branch could be traced through the whole brain entirely free from disease. The vertebral arteries were also much affected, especially theieft, which was much enlarged, and its coats thickened, ossified in spots, and brittle. The state of the arteries in such a case as this, with the partial separation of the inner coat, could not fail to be pro- ductive of much disturbance of the circulation, and much de- rangement of the functions of the brain. Another case will be afterwards mentioned in which a similar disease appeared to have led to frequent paralytic attacks ; the patient died at last of gangrene of the toes. (Case CXIX.) See also the disease in the basilar artery described in case XXXII., in which it was entirely obstructed and distended by a firm white matter, without any appearance of blood. It appears that a disease somewhat similar occurs in the veins of the brain, as in the following remarkable case with which I have been favoured by Dr. Cheyne of Dublin. Case CXV1I.—A lady, aged 42, was of a melancholy temperament, and had been subject to headachs from early life. About ten years before her death she lost her husband under circumstances of peculiar distress, and from that time confined herself to the house and laboured under the greatest APOPLEXY WITH EXTRAVASATION. 261 dejection of mind. She was liable to frequent attacks of bi- lious diarrhoea, and her old headachs became more constant and more severe. In one of these attacks she became apo- plectic and died. Inspection.—There was a turbid effusion betwixt the arachnoid and pia mater, and the whole surface of the brain was blood-shot. The venous system of the brain was diseased after an unusual manner. There was a deposition of a firm yellowish-white substance between the lining and outer coat of the veins; it was universal allover the brain, giving to the veins a mottled or rather ribbed appearance. The appear- ance of the whole of the arterial system was precisely the same as the venous, and both the arteries and veins were thicker but more fragile than usual. The medullary portion of the brain was more than usually vascular; on the inner side of the posterior horn of the left lateral ventricle, there was an irregular cavity about an inch in length and half an inch in breadth. The portion of the brain, which formed the walls of the cavity was much diseased, soft and yellow ; its structure was destroyed, and it was penetrated by a num- ber of enlarged and unsupported vessels. The left choroid plexus contained an hydatid the size of a large pea. This important subject has been little investigated, but there seems every reason to believe that disease of the ve- nous system of the brain may have a most extensive influence in the affections of that organ. Various examples of this class will be found in the preceding observations, particularly the complete obstruction of the lateral sinus which occurred in Cases IV. and V., and the remarkable disease of the veins on the upper surface of the brain in Case XXVIII. The sub- ject is worthy of careful investigation and promises important results. A lady mentioned in the Revue Medicale, torn, xxi., having been exposed to mental agitation on the seventh day after accouchement, became insensible and continued so for three quarters of an hour. On her recovery, she complained 262 PARALYTIC CASES. of acute pain in the left side of the head, which continued with little change for ten days, notwithstanding topical bleed- ings, and various other remedies. There was then a great and sudden increase of it, accompanied by pain in the left ear, and this was soon followed by palsy, first of the right arm, and soon after of the right leg. Three days after this there was loss of speech with partial stupor, then convulsive at- tacks, and strabismus; and she died on the 17th day of the disease. On inspection, the middle cerebral vein on the right hemisphere, where" it approached the longitudinal sinus, was found very large and containing a puriform substance which entirely filled it: and the corresponding vein, on the left side was in the same state. In removing the falx, a flattened tumour was discovered between two and three inches long, and ten lines in thickness. It occupied the seat of the lon- gitudinal sinus, and appeared to be formed of a cellular tissue injected with blood. SECTION III. OF THE CASES OF THE THIRD CLASS, OR THE PARALYTIC . CASES. Under this class I have included a description of cases which resemble each other in their symptoms only, but are found to differ most remarkably in the morbid conditions of the brain with which they are connected. We are not pos- sessed of sufficient information to enable us accurately to dis- criminate them from each other; and all that we can attempt at present, is to give a statement of the facts relating to them, under a simple arrangement. The leading phenomenon of this class is the paralytic at- tack without coma, or at least without that complete and per- manent coma which occurs in the former classes. Some of those cases, indeed, which begin as a paralytic attack, after a certain time pass into apoplexy, the paralytic attack being VARIOUS FORMS OP THE PARALYTIC ATTACK. 263 only the prelude to, or the first stage of, the apoplectic ; these of course belong to another class, particularly the second. The cases which I mean to include under this third class are those in which, either there has been no apoplexy, or the apoplectic state has soon passed off, leaving the paralysis as the more prominent and permanent character of the dis- ease. The attack appears under various forms, the most common of which is hemiplegia with loss of speech; but in some cases the speech is not affected; while in others the loss of speech is at first the only symptom. In some cases, again, one limb only is affected, which is most commonly the arm, though sometimes the leg. Numerous other modifications occur, as, palsy of one eyelid; or of the orbicularis of the eye; distortion of the eyes; double vision; twisting of the mouth, &c. Loss of the power of swallowing also occurs occasionally,"though more rarely in the cases which do not pass into apoplexy. The pa- tient frequently appears quite sensibleof his situation,and makes anxious attemps to express himself; generally understanding in a great measure what is said to him, and answering by signs. Sometimes, however, when he retains a partial power of speech, his answers are incoherent and unintelligible. In the farther progress of cases of this class, we observe re- markable varieties which may be chiefly referred to the fol- lowing heads. I. Such an attack may be merely the prelude to the apo- plectic, and may pass into it after a short interval. These cases belong chiefly to the second class. II. The attack may, under the proper treatment, pass off speedily and entirely, leaving, after a very short time, no trace of its existence. III. The recovery may be very gradual, the use of the affected limbs being restored after several weeks or months. IV. The palsy may be permanent; that is, the patient, af- ter a certain time, may recover so far as to be able to walk 264 PARALYSIS WITH SEROUS EFFUSION. about, dragging his leg with a painful effort, and to speak very imperfectly; and after this, makes no farther improvement to the end of his life, which may be protracted for many yeare. V. In a fifth variety the patient makes no recovery; he is confined to bed, speechless and paralytic, but possessed of his other faculties in a considerable degree, and dies gradually exhausted, after several weeks or months; in some cases with- out coma, in others with coma for a few days before death. In endeavouring to investigate the morbid conditions of the brain which are connected with these varieties, we find con- siderable diversities, which, in a pathological point of view, may be referred to the following heads. I. Many of the cases appear to have a close analogy to simple apoplexy; and when they are fatal, present either no satisfactory appearance, or only serous effusion, often in small quantity. II. Extravasation of blood of small extent, contained in de- fined cysts in the substance of the brain or under the mem- branes. III. Ramollissement of the cerebral substance. IV. Inflammation and its consequences. § I.—Paralytic cases, with serous effusion, or with SLIGHT MORBID APPEARANCES. When a paralytic attack of the most formidable appearance passes off speedily and entirely, without leaving any trace of disease, we may suppose that no very serious injury has been done to the substance of the brain; and that the disease bears a close analogy to the affection which I have termed Simple Apoplexy; or, in other words, that the cause had consisted of a state of the circulation of the brain, which is capable of be- ing speedily and entirely removed. Many cases again are fatal, and present, on dissection, only serous effusion, often in small quantity. A man, mentioned by Morgagni, had palsy PARALYSIS WITH SEROUS EFFUSION. 265 of the right arm, and died apoplectic in two days. On dis- section, no morbid appearance was discovered, except serous effusion, both in the ventricles and on the surface of the brain. Another had loss of speech, and palsy of the left side, and died comatose at the end of a month. Considerable effusion was found on the surface of the brain, but very little in the ventricles. A third had loss of speech and palsy of the right side, then became comatose, and died in five days. The ven- tricles contained about two ounces of fluid: there was also a good deal on the surface of the brain, which appeared to be most abundant on the right side. I have formerly given my reasons for believing, that serous effusion in apoplectic cases is not a primary disease, but a ter- mination of simple apoplexy; and I have described cases in which it existed to a considerable extent without paralysis. In the cases, again, in which it has been accompanied by pa- ralysis, the quantity of fluid has borne no proportion to the symptoms, and has been equally distributed over the brain; except in the case now quoted from Morgagni, in which too, it is worthy of remark, it appeared to be most abundant on the same side with the disease. From these considerations, I think we may conclude, that, in the cases now referred to, the effusion was not the cause of the paralysis, but the effect or the termination of a certain state of the circulation in a part of the brain, with which the paralysis had been connect- ed from the first invasion of the disease. The whole pheno- mena of palsy, do indeed bear evidence, that certain cases of it depend upon a cause, which is of a temporary nature, and capable of being very speedily and entirely removed. We see hemiplegia take place in the highest degree, and yet very rapidly disappear; but the most singular circumstance, con- nected with certain cases of palsy, is, that we occasionally see it continue without any improvement for many weeks or months; and then, from some change which entirely eludes our observation, take a turn for the better, and very suddenly disappear. 266 PARALYSIS WITH SEROUS EFFUSION. I do not know to what class I ought to refer the following case, but I shall introduce it here as the most remarkable ex- ample that has occurred to me, of long-continued palsy, with- out any satisfactory morbid appearance. Case CXVIII.—A gentleman, aged 35, while standing in the street,conversing with a friend, suddenly lost his speech; he recovered it after a few minutes, walked home, and made no particular complaint. In the evening of the same day, he suddenly fell from his chair, speechless, and paralytic on the right side, but without coma; being sensible of what was said to him, and answering by signs. He was then confined to bed for several weeks without any change in the symptoms. At the end of three months, he had recovered so far £he mo- tion of his leg, as to be able to walk a little, dragging forward the leg by a motion of the whole right side of his body. He afterwards improved considerably in bodily strength, so that he could walk for several miles; but his thigh and leg con- tinued to be dragged forward by the same kind of effort, with- out any farther improvement. He never recovered any de- gree of motion of the arm or hand: he could not even move the fingers; his speech was very inarticulate, and his counte- nance was expressive of great inbecility of mind. In this state he continued without relapse, and without any farther improvement, for fifteen years, when he died at the age of 50. For a month before his death, he had been declining in strength. I saw him about four days before he died, and found him in a state resembling typhus; his pulse frequent and weak; his tongue very foul, and dry in the middle; he made no com- plaint. He was not then in bed, but was confined to it next day, and died in three days more, of rapid sinking without coma. Inspection.—The membranes adhered firmly to each other, and to the brain, at a spot the size of a shilling, on the upper part of the right hemisphere. There was a large quantity of fluid under the arachnoid membrane, and a con- PARALYSIS WITH DISEASED ARTERIES. 267 / siderable quantity in the ventricles. Near the posterior part of the longitudinal sinus, a small part of the sinus appeared to be thickened in its coats, and the inner surface of this part was dark-coloured and slightly fungous. The cauda equina was of a refmarkably dark colour, as if it had been soaked in venous blood, but without any change in its stucture. No other morbid appearance could be detected, on the most care- ful examination, in any part of the brain or spinal cord. The remarkably diseased state of the arteries of the brain, which has been already referred to, as a very common ap- pearance in elderly people, may probably be the cause of temporary interruptions of the circulation, and slight paralytic attacks, which after some time may pass off from changes which elude our observation. Perhaps something of this kind occurred in the following case, for which I am indebted to Dr. Simson. Case CXIX.—A gentleman, aged 58, in 1805, was attacked with hemiplegia of the right side, without coma. After the usual treatment, he improved gradually; and at the end of five months, he had quite recovered, except that his right leg continued rather weaker than the other. In 1812, he had another attack, preceded by violent headach. From this likewise he gradually recovered, though his recovery was much less perfect than after the former attack. He had four other attacks betwixt 1812 and 1817, which were carried off by the usual remedies, blood-letting and purging. In 1817, he had another and severe attack, likewise in the right side* his speech was unintelligible, and his mouth much drawn to the left side. He was relieved by blood-letting, &c. but from the effects of this attack he did not recover. He remained paralytic in the right side, his mouth twisted, and his speech very indistinct. In November, 1818, he began to be affected with gangrene of the toes, which advanced slowly, and ter- minated fatally, in April, 1819. From the time of his first 268 PARALYSIS WITH EXTRAVASATION. attack, in 1805, to the second, in 1812, he always became confused and felt headach, when he attempted to read or write, so that he was obliged immediately to desist; but after the attack in 1812, he was able to read and write without any confusion or uneasiness, and even without the use of specta- cles, which he had formerly employed. Inspection.—The dura mater seemed considerably thick- ened; the pia mater also seemed thickened, and was very vas- cular. There was extensive disease in the arteries of the brain, their coats being thickened, and in many places ossified. This was very remarkable in the principal trunks of the ca- rotids and vertebrals, and was likewise traced into smaller branches. The internal carotids seemed considerably larger than usual, and their coats were much thickened; and the vertebrals and their branches were affected in the same man- ner in a still greater degree, particularly about the tuber an- nulare, where the basilar artery was quite brittle, and gave off its branches in the same condition. § II.—Paralytic cases accompanied by extravasation OF BLOOD OF SMALL EXTENT. The symptoms which appear in connexion with extravasa- tion of blood in the brain, seem to depend in a great measure upon the quantity that has been extravasated. In the cases which go on to apoplexy, the blood seems in general to burst by laceration of the cerebral substance, either to the surface, or into the ventricles. In the paralytic cases, it seems to be confined to a certain defined cavity in which the haemorrhage at first took place. This may be in any part of the substance of the hemispheres; the corpus striatum is a very common seat of it; and it may be found in the substance of the pons Varolii, or of the medulla oblongata. It may likewise take place on the surface of the brain, as in Case CXXV, in which the cyst which had contained it was distinctly seen in the cel- lular structure of the arachnoid. Extravasation of a certain PARALYSIS WITH EXTRAVASATION. 269 extent, either in the substance or on the surface, seems, in ge- neral, to produce palsy of the opposite side; and as the quantity increases, the case seems to pass into apoplexy; but it appears that extravasation may take place and produce fatal apoplexy without having induced paralysis. Several cases have been already described in which this took place, though in all of them there was a considerable interval betwixt the attack and the occurrence of coma. When the extravasation is of more limited extent, so as to be confined to a cavity of moderate size in the substance of the brain, the patient is in general affected with palsy and loss of speech, without perfect coma; or, if there be coma for a time immediately after the attack, it passes off after a cer- tain interval, and the prominent character of the disease comes to be the state of paralysis. In the farther progress of the cases of this class, we find remarkable varieties. Some of them pass, after a certain time, into fatal coma, even when the extravasation of blood is of no great extent; while, on the other hand, we shall find that the patient may recover entire- ly from the effects of extravasation of a certain extent, and may even recover from the immediate effects of very exten- sive extravasation, and survive in a paralytic state for many years. The cause of this difference seems to depend, in a great measure, upon the state of the surrounding cerebral sub- stance. When extravasation of small amount is fatal, it seems in general to be connected with ramollissement of the cerebral substance to some extent around the cavity which contains the coagulum. There is also some reason to believe, that ex- travasation of very small extent, in fatal cases, may sometimes be considered as the effect of the state of simple apoplexy; and that, in these instances, the fatal event is not to be as- cribed to the extravasation, but to the state of simple apo- plexy, which we have seen may be fatal without either ex- travasation or effusion. This may be considered as in some measure conjectural, but the other is more a matter of fact; namely the effect of ramollissement of the cerebral substance 35 270 PARALYSIS WITH EXTRAVASATION. surrounding the coagulum in producing a fatal disease, while we see in other cases, extravasation of greater extent entirely recovered from. The ramollissement in these cases seems to arise from a diseased state of the arterial system of the part, the same probably which generally gives rise to the extrava- sation. When the cerebral substance surrounding the extravasation continues in a healthy state, we find that coagula of very great size are gradually and completely absorbed. This remarka- ble change seems to commence at a very early period, but to advance very slowly. When we have an opportunity of see- ing the coagulum, so early as fourteen or fifteen days from the attack, we find it already considerably changed in its cha- racter from the appearance of recent blood. The thinner parts have considerably disappeared, and the coagulum has become firmer in its texture, and of a dark brownish colour. In its farther progress, it assumes a firm and fibrous texture; the dark red colour is gradually lost, and the last portion that remains is a small mass of fibrine of a slight reddish colour, which, after a certain time, also entirely disappears. The time required for this process must of course depend in a great measure upon the size of the coagulum, but seems likewise to be in part regulated by other circumstances. In Case CXXI., a coagulum, which must have been of very considerable size had entirely disappeared in less than five months. In Case CXXIV., it was seen partly absorbed at the end of three months. On the other hand, Moulin found a small coagulum not quite gone at the end of a year; and Riobe observed some of the blood still remaining in a cavity of small extent, after twenty months. In two cases, Serres found a hard coagulum of blood remaining, in the one at the end of two years, and in the other at the end of three years. While these changes are going on in the coagulum, the ca- vity in which it is contained becomes lined with a distinct firm membrane of a yellowish colour; and when the coagulum ABSORPTION OF THE COAGULUM. 271 has entirely disappeared, we find the cyst remaining, and forming a distinct and well defined cavity, which is generally entirely empty. Bands of the same yellow matter which forms it are frequently seen crossing it in various directions, and producing a connexion betwixt its opposite sides at these points. The French writers believe that the cyst is at last entirely obliterated; but I have never seen any thing to satis- fy me that it is so. I have examined such cysts at various periods of their progress, but have seen nothing like an ap- proach to obliteration, except the bands which I have now mentioned, connecting their opposite sides. The cyst appears to be distinctly organized, and numerous blood vessels have sometimes been observed ramifying upon it. It does not ap- pear precisely at what period this remarkable membrane is deposited. Riobe describes it in one case, as existing three weeks after the attack; and, in another, he thought he ob- served the formation of it begun in a very soft state as early as thirteen days. In the cases which I have had an opportu- nity of observing, after the disappearance of the coagulum, the cyst has in general been entirely empty. It appears, however, that it has been frequently observed by the French writers full of serous fluid. Their idea is, that serous fluid is deposited from the exhaling vessels of the membrane, and is again absorbed, after dissolving a part of the coagulum; that in this manner the coagulum gradually disappears; and that the membrane then continues to deposite and reabsorb the se- rum, until the cavity is obliterated. I have already stated, however, that in my observation, cavities even of large size are found entirely empty. Moulin has described a case of seventeen years' standing, in which the patient had continued paralytic, with wasting of the affected limbs, and had never recovered his speech. He found a cyst containing four ounces of fluid which was tinged with blood. As the absorption of the coagulum goes on, the symptoms in some cases subside gradually, and entirely disappear; but 372 PARALYSIS WITH EXTRAVASATION. in others the improvement is but partial, and we find that the coagulum had been entirely removed, while the patient con- tinued to be affected with a great degree of palsy to the end of his life. In other cases again the symptoms appear to go off speedily, though there was every reason to believe that a coagulum was present, and could not yet be absorbed. This probably occurred in Case CXXIV. It appears that extra- vasated blood may be absorbed in the same manner from the ventricles, though in cases of this kind it more rarely occurs in that situation. A man, mentioned by Riobe, had an attack of apoplexy, which left him affected with palsy of the left side. He improved very gradually, and was entirely reco- vered at the end of 18 months, when he died of peripneumo- ny. In the right lateral ventricle, there was a small quantity of coagulated blood, and the membrane lining the ventricle, was of a yellowish colour, and much thickened. In Case CXXV., I have described an example of absorption from the surface of the brain, the cyst being formed in the cel- lular structure of the arachnoid, but having the same charac- ters as the cysts which are found in the substance of the brain. The following selection of cases arranged under several heads, will illustrate this modification of the disease. I shall describe the first case at some length, as it shows verv re- markably the various stages of this interesting affection. A. The cyst empty—the patient dying of another disease. Case CXX.—A clergyman, aged 29, had complained for several weeks of frequent headach, which affected him chiefly in the morning. On Tuesday, 30th November, 1819, he walked out in his usual health about 11 o'clock in the fore- noon, and about half an hour after went into a shop, when he was found to be speechless, and with his mouth twisted to one side. He was immediately taken home; he had then the ABSORPTION OF THE COAGULUM. 273 Use of all his limbs, and was able to walk about his room; he talked incoherently and inarticulately, his mouth was very much twisted to the left side, but he seemed to know his friends. Soon after, he became more incoherent and partially comatose, but resisted violently when he was bled. Pulse of natural frequency. I saw him soon after the bleeding; he was then rather pale, and the pulse natural; he made eager at- tempts to speak, and when disturbed, sometimes became vio- lent; but his speech was quite inarticulate, and he did not ap- pear to comprehend what was said to him. After farther bleeding, purging, the necessary effect would be a corresponding diminution in the other, because the whole mass of blood in the brain, must, by the supposition, remain the same. Hence would arise a derangement of the circulation, such as could not occur in any other part of the body, because there is no other organ so situated as the brain. We must be cautious, however, of speculating, where it is difficult to avoid falling into error, and must satisfy ourselves with attempting to trace, in a very general manner, the various ways by which, in such an organ as the brain, derangements of circulation may be supposed to take place. I. Let us take a very plethoric state of the body, in which the general vascular system is loaded with more than the ave- rage or healthy quantity of blood. The arteries going to the head will partake of this general condition, and there will be an effort or impulse which tends to propel an undue quantity of blood into the arteries of the brain. Though no addition to the whole quantity of blood in the brain can actually take place, because the vessels of the brain are already full, the constant impulse will be such as tends to introduce an addi- tional quantity, and consequently tends to derange the healthy relation betwixt the arterial and venous systems; for any in- crease of quantity in the one system, if such actually took place, would lead to a corresponding diminution of the quan- tity in the other. Let us say, for example, that the whole blood circulating in the brain is as ten, and that it is divided between the arteries and veins as five to five. In the loaded state of the system now referred to, we can suppose a case, in which, by some sudden impulse from the general circula- tion, the arteries of the brain are, at a particular moment, dis- ON THE CIRCULATION IN THE BRAIN. 317 tended by a quantity as six. In any other part of the body, this would be followed by a similar distention of the corres- ponding veins, and the healthy balance of the circulation would be speedily restored. But in the brain, the very re- verse would happen; for as the whole mass of blood must continue as ten, if the arteries were distended by a quantity as six, the quantity in the veins must be diminished to four, because the increased capacity in the one system of vessels, can be gained only by a corresponding diminution of capacity in the other. The result of the condition so produced would be the following. The veins of the brain would contain a quantity of blood as four, while the arteries would contain a quantity as six. The quantity transmitted by the veins would be the measure of the quantity that could enter the ar- teries from the general circulation, namely, a quantity as four. But the impulse from the general circulation would be such as tended to introduce a quantity as six, supposing the con- tinuance of the undue impulse from which the disease origi- nated, or a quantity as five, supposing the impulse to have subsided to the state of health. In either case the- impulse would be such as tended to introduce a greater quantity than could enter, and consequently to keep up the deranged state of the cerebral vessels which had taken place. The farther result of this would be, an increased flow of blood into the external vessels of the head, producing probably flushing tur- gidity of features, and other marks of increased determination to the external parts. But I forbear to press the speculation so far as to inquire, whether, in a certain plethoric state of the system, aided, perhaps, by some accidental impulse in the ge- neral circulation, such a derangement as this does take place in the cerebral vessels ; and whether, when it reaches a cer- tain point, it may give rise to the paroxysm of simple apo- plexy. IL If there be any considerable interruption to the re- turn of the blood from the veins, of the brain, a derange- 41 318 ON THE CIRCULATION IN THE BRAIN. ment will take place very analogous to that supposed under the former head. If the quantity of blood which is actu- ally returned by the veins be considerably diminished, there will be a corresponding diminution of the quantity which can enter the arteries. The healthy impulse from the general circulation will then become, in reference to the actual state of the circulation in the brain in this case, what the undue impulse was in the other. But I forbear here also from urging the inquiry, whether such a derange- ment as we have now supposed might take place from causes retarding the return of blood from the head, such as tu- mours on the neck, and eertain affections of the heart and lungs; and whether, if it did take place, it might give rise to symptoms analogous to simple apoplexy. Two points, however, may be briefly alluded to in re- gard to the parts of this speculation referred to under the two preceding heads. (1.) If such a derangement, as has been supposed, really took place in the vascular system of the brain, it would follow, that the impetus from the gene- ral circulation would be such as tended to introduce into the arteries of the brain a larger quantity of blood than could actually enter. One effect of this would be an in- creased flow of blood into the external vessels of the head, and there are various facts which tend to show that some- thing of this kind does actually take place in the apoplec- tic attack—as the flushing of the face, turgidity of the fea- tures, throbbing of the external vessels, and other appear- ances which have been referred to the doctrine of determi- nation to the head. Numerous writers have remarked the unusual quantity of blood which is discharged from the in- teguments, in opening the heads of persons who have died of apoplexy. In some of Dr. Cheyne's dissections, up- wards of a pound was collected in this manner; and Dr. Kellie made the same observation on the two men whom he examined after execution. Mr. John Bell remarks, that having injected the head of a person who died of an affec- ON THE CIRCULATION IN THE BRAIN. 319 tion of the brain, he found the features so distorted by the injection, the lips so protruded, and all the superficial ves- sels so much enlarged, as to make the preparation useless. The remarkable turgidity of the features and of the neck, which often occurs in apoplectic cases, must indeed be fa- miliar to every one; and it appears to be most remarkable when the disease has proved rapidly fatal, without any means having been employed. A gentleman, whom I saw with Mr. White, after some symptoms showing an apo- plectic tendency, was one morning found dead in bed, his body being scarcely cold. His neck and features were of a deep purple colour, and turgid in a most uncommon degree, but no turgidity was observed in the vessels of the brain. (2.) Upon the grounds already referred to, there is reason to believe, that we cannot, by our evacuations, diminish in any material degree the quantity of blood in the head. But if these conjectures shall be considered worthy of any credit, it will appear probable, that the effect of our eva- cuations will be to take off from the cerebral vessels, the excessive impulse from the general circulation, or even to reduce it below what would now be considered as a healthy impetus, and thus to leave the vessels of the brain in a state favourable for recovering their healthy relations. III. A similar derangement might be supposed to take place from causes which directly diminish the capacity of the venous system of the brain. If a depression has been produced of a portion of bone, so as considerably to en- croach upon the cavity of the cranium, or if a coagulum of blood has been deposited, so as to occupy a considera- ble space upon the surface of the brain, the diminution of space thus produced would probably affect chiefly or en- tirely the venous system of the brain. It would not di- minish the quantity of blood which tends to enter the ar- teries of the head, but it would diminish in proportion to its extent the capacity of the veins, and thus derange the 320 ON THE CIRCULATION IN THE BRAIN. relations betwixt the two systems of vessels, in a different manner from that which has been supposed under the for- mer heads, but analogous in its effects upon the circulation in the brain. When, in the former of the cases now sup- posed, the depressed portion of bone has been elevated, the two systems recover their healthy relations, and the symptoms disappear. It is probable that a cause of this kind may exist in a smaller degree, in which it shall not produce any perma- nent interruption of the circulation in the brain, but may give rise to derangement when there is any occasional in- crease of impetus in the circulation. In the first part of these essays, I have described a remarkable case, in which a tumour, formed by deposition betwixt the lamina? of the dura mater, occupied a considerable space on the surface of the brain. The patient had experienced littl6 inconve- nience from it when he was at rest, but, when in motion, he was liable to attacks of an apoplectic nature, from which he recovered in a few minutes. A gentleman, men- tioned by Lancisius, who had long suffered from hemicra- nia, was seized about the age of 50 with intense pain in the temple, and soon after had an attack of apoplexy, from which he speedily recovered; but from this time he had an apoplectic attack "once or twice every month. This went on through the following autumn and winter, and he at last died suddenly in one of the attacks. Under the right side of the os frontis, the membranes were much thickened, and, connected with the thickened portion, there was a kind of polypus on the surface of the brain. In cases such as these, it is probable, that, when the circulation is in a very tranquil state, or when the general mass of blood has been reduced by evacuations, the*circulation in the brain goes on in a healthy manner; but that any increase of the quantity of the blood, or any considerable increase of its impetus, leads to the derangement. It is probable that si- milar affections might be traced to causes diminishing the ON THE CIRCULATION IN THE BRAIN. 321 area of the sinuses, or of the principal veins of the brain; and I have formerly mentioned some remarkable cases, in which frequent attacks of an apoplectic and paralytic na- ture appeared to be connected with extensive disease of the arteries of the brain. Facts are wanting on this inte- resting subject; but many cases are on record in which an individual has suffered in a few years fifteen or twenty apoplectic attacks, without experiencing in the intervals any bad effects from them. Minute attention to such cases may probably lead to results calculated to throw much light upon the pathology of apoplexy. IV. There are many interesting facts which lead us to believe, that the circulation in the brain may be deranged in a manner remarkably different from any of the preceding cases. Let us suppose that the general volume of blood in the body is very much diminished. The effect of this upon each individual artery is, that its calibre is contracted, and that it acts upon the veins with which it is connected with diminished momentum. The arteries of the brain will partake of the general state of the system, so that the quantity of blood transmitted to the head will be diminished in the same ratio. But while this change is going on, a corresponding accumulation would probably be taking place in the veins, because the whole quantity in the head must continue the same. Upon this increased mass of blood, the volume in the arteries would now act with a corres- pondingly diminished and inadequate impetus. It is pro- bably in this manner that there arises the appearance of congestion in the superficial veins of the brain, which has been observed in animals that have been bled to death; and many curious facts occur to us in practice, which ap- pear to be referrible to a derangement of the circulation in the brain, which can only be accounted for in this manner. 322 ON THE CIRCULATION IN THE BRAIN. I shall relate some of these facts without indulging farther in speculation. A gentleman, aged about forty, had been for some time losing considerable quantities of blood by arterial hae- morrhage from the rectum. Considering it as merely hae- morrhoidal, he had paid little attention to it, until his friends became alarmed by his altered appearance. From being strong and rather plethoric, he had become weak, exhaust- ed, pale, and haggard. He had anasarca of his legs—his pulse was frequent and feeble, and much excited by the least exertion. Along with these symptoms, he was liable to strong and irregular action of the heart, and complained of giddiness, tinnitus aurium, violent throbbing in the head, and frequently of throbbing headach. On examin- ing his rectum, a fungous tumour was found within the sphincter, on the apex of which a small artery was bleed- ing per saltum. This was tied, and th*ere was no return of the haemorrhage; and under the use of nourishing diet, and a liberal allowance of wine, all his other complaints disappeared. He made up so rapidly in flesh and blood, that not long after, apprehensions were entertained that he was becoming too plethoric, and it became necessary to re- duce his regimen, but under these circumstances he had no return of the symptoms in his head. A lady, aged twenty-five, had been frequently bled on account of symptoms in the head which had supervened upon an injury. Considerable relief had followed each bleeding; but the symptoms had soon returned so as to lead to a repetition of the bleeding at short intervals, and this had beengoing on for several months. When I saw her, she was stretched upon a couch, her face of the most death-like paleness, or rather of the paleness of a stucco figure, her pulse very rapid and as small as a thread, her general weakness extreme. The mass of blood appeared to be reduced to the lowest point that was compatible with ON THE CIRCULATION IN THE BRAIN. 323 life, but she still complained of frequent headach, violent throbbing in the head, confusion and giddiness. It was evident that evacuations could be carried no farther, and in consultation with a very intelligent medical man who had the charge of her, it was agreed as a last experiment to make trial of the opposite system, nourishing diet and tonics. In a fortnight she was restored to very tolerable health. I have been repeatedly consulted under the following circumstances. A gentleman accustomed to very full living, is seized with an apoplectic attack, or with symp- toms indicating the most urgent danger of apoplexy; he is saved by bleeding and other free evacuations, and is kept for some time upon a very spare diet. His complaints are relieved, and as long as he keeps quietly at home, he goes on without any uneasy feeling. But when he begins to go abroad, he becomes liable to attacks of giddiness and confusion, generally accompanied by palpitation of the heart and an uneasy feeling about the praecordia. His pulse is now soft and rather weak, and his general appearance indicates the very reverse of plethora; and these symp- toms are removed by a cautious improvement of his regi- men. This curious fact I have repeatedly had occasion to attend to in the treatment of cases of this kind, and it has always appeared to me to be one of very great interest in reference to the pathology of the brain. Various other facts will present themselves to the practical physician, which bear upon this curious subject. In the last stage of diseases of exhaustion, patients frequently fall into a state resembling coma, a considerable time before death, and while the pulse can still be felt distinctly; and I have many times seen children lie for a day or two in this kind of stupor, and recover under the use of wine and nourishment. It is often scarcely to be distinguished from the coma which ac- companies diseases of the brain. It attacks them after some continuance of exhausting diseases, such as tedious and nc- 324 ON THE CIRCULATION IN THE BRAIN. glected diarrhoea; and the patients lie in astate of insensibility, the pupils dilated, the eyes open and insensible, the face pale', and the pulse feeble. It may continue for a day or two and terminate favourably, or it may be fatal. This affection ap- pears to correspond with the apoplexia ex inanitione of the older writers. It differs from syncope in coming on gradually, and in continuing a considerable time, perhaps a day or two; and it is not, like syncope, induced by sudden and temporary causes, but by causes of gradual exhaustion going on for a considerable time. It differs from mere exhaustion, in the complete abolition of sense and motion, while the pulse can be felt distinctly, and as in some cases of tolerable strength. I have seen in adults the same affection, though it is perhaps more uncommon than in children. A man considerably ad- vanced in life, in consequence of a neglected diarrhoea, fell into a state closely resembling coma; his face pale and col- lapsed, but his pulse of tolerable strength. An elderly lady, from the same cause, had loss of memory and squinting. Both these cases recovered by wine and opiates; in the former, blistering on the neck was also employed. Richter states that amaurosis has been produced by haemorrhage, cholera, and tedious diarrhoea; and he mentions particularly a dropsical woman, who became blind when the fluid was evacuated from her abdomen by tapping. On this interesting subject, I shall at present only add the following remarkable illustration from an affection of hearing. A gentleman about 30 years of age, came to Edinburgh from a distance for advice in regard to an obscure affection, referred chiefly to the stomach, which had reduced him to a state of extreme weakness and emacia- tion. As the debility had advanced, he had become conside- rably deaf, and when I saw him he was affected in the follow- ing manner. He was very deaf while sitting erect or stand- ing, but, when he lay horizontally, with his head very low, he heard perfectly. If, when standing, he stooped forward so as to produce flushing of his face, his hearing was perfect, and, upon raising himself again into the erect posture, he con- ON THE CIRCULATION IN THE BRAIN. 325 tinued to hear distinctly as long as the flushing continued; as this went off the deafness returned. Upon the whole, it seems highly probable that a ceitain ba- lance of the circulation of the brain is necessary for the heal- thy condition of its functions; that they are equally impeded by the interruption which takes place in apoplexy, and the diminished impulse which occurs in syncope and in many af- fections of extreme exhaustion; and that there is a remarka- ble similarity in the symptoms which occur in these opposite conditions. What indeed is syncope, but an abolition of sense and motion? It is preceded by giddiness, tinnitus aurium, and impaired vision, and is accompanied by blindness, dilated pupil, perfect insensibility, and not unfrequently passes into convulsion. It differs then from apoplexy, chiefly or entirely in the state of the general circulation, the symptoms accom- panying the two affections being remarkably similar, and the effect upon the sensorial functions almost entirely the same. Here however some questions occur: If the circulation in the brain be so nicely and so peculiarly balanced, why is it not seriously deranged by the numerous changes which are constantly occurring amid the variety of circumstances to which the body is exposed? Why is not apoplexy produced by every increase in the mass of blood, or why is it not ex- cited by every instance of intemperance, violent exercise, or strong mental emotion? Is there any provision by which the effects of these causes are averted in their daily occurrence, though in a certain condition of the system, each of them may be capable of producing perfect apoplexy? It seems proba- ble that there are several circumstances in the anatomy of the head, which contribute to this important end, but I shall merely allude to them without entering upon the speculations to which they might lead. One is, that all the arteries of the brain enter the head through continued canals of bone. These appear to have considerable influence in arresting any sudden impulse of blood, and in directing it offto the external branches. Hence the flushing of the face,* turgidity of the features, and 42 326 ON THE CIRCULATION IN THE BRAIN. throbbing of the external vessels, which often occur in such cases, while no affection in the brain follows. Another cir- cumstance, which seems to contribute to the same purpose, is the peculiar structure of the sinuses of the dura mater. These at all times must contain a considerable proportion of the venous blood of the brain, and from their peculiar struc- ture it seems probable that they are not liable to have their area either increased or diminished in any considerable de- gree. This remarkable structure must operate very conside- rably in preventing those derangements of the circulation which have been referred to in the preceding speculations, and which, in an organ situated as the brain is must otherwise have taken place from very slight causes. PART III. OF THE ORGANIC DISEASES OF THE BRAIN. By organic diseases of the brain we understand, either per- manent changes of the cerebral substance itself, or new for- mations within the head. These may be either embedded in the substance of the brain, or attached to its surface. The principal forms under which we meet with these affections may probably be referred to the following heads: I. Tumours formed by thickening of the membranes of the brain, or by deposition of new matter betwixt their lamina?. Of this I have already given a very remarkable example, (Case VI.) in which a tumour five inches long, three inches broad, and half an inch in thickness, was formed in this man- ner by a deposition of new matter betwixt the laminae of the dura mater. II. Deposition of a pellucid or semi-pellucid substance having the characters of albumen. This may either be formed in undefined masses under the membranes of the brain, par- ticularly under the arachnoid, as in Case LXXXVIII. or con- tained in distinct cysts in various parts of the brain, as in the Cases LXXXVI. and LXXXVII. The substance which is deposited in these cases coagulates into a firm mass in the heat of boiling water. It is met with in various degrees of consis- tency, and there is some reason to believe that it undergoes some remarkable changes in density, assuming a firmer texture in certain stages of its progress. 328 ORGANIC DISEASES OF THE BRAIN. III. A very dense tumour, of a uniform whitish or ash co- lour, and exhibiting the appearance and the properties of co- agulated albumen. This substance is found in distinct round- ed tumours of various sizes, which are generally attached to the dura mater, and do not appear to be covered by any cyst. I have described one which grew on the falx in Case LXXXIII. nearly five inches in circumference, and uniform- ly white and firm in its consistence; it did not appear to be organized, and when analyzed exhibited the properties of co- agulated albumen. The remarkable circumstance in this case was, that no urgent symptoms arose from the presence of this mass until a few weeks before death. Tumours of this kind sometimes arise from the external surface of the dura mater; in this case they have been frequently known to pro- duce absorption of the bone, and to rise externally under the integuments of the head, so as to be mistaken for wens. Many cases of this kind are mentioned by the French writers. In some of them, the disease seems to have been originally excited by injuries; and in others, an injury appears to have accelerated the process by which the tumour was making its way through the bone. When these tumours have been rashly meddled with by incision, death has generally been the consequence. Small tumours, which resemble those of this class, are sometimes met with attached to the choroid plexus. I have seen one in each lateral ventricle, the size of small hazel nuts, in a man who died suddenly after having had re- peated epileptic attacks at long intervals, and having been for some time affected with symptoms threatening apoplexy. IV. Tumours externally resembling those of the former class, but internally presenting an organized appearance, and a reddish or flesh-colour, resembling the substance of the kid- ney. These are met with in various situations; one will be described, the size of an egg, which grew from the tentorium. The two appearances, described under this and the former heads, seem to include the most common characters of what may be properly called tumours of the brain. Steatomatous ORGANIC DISEASES OF THE BRAIN. 329 and fatty tumours are likewise described, but they appear to be more uncommon. V. Tubercular disease. Of this very frequent appearance several examples have already been given. It occurs in masses, varying in size from the smallest size to that of an egg; and these may be either embedded in the substance of the brain, or attached to the membranes. In their earlier stages, they present to us a whitish-coloured cheesy matter, gene- rally enclosed in a cyst; but, in their more advanced forms, we generally find them presenting a greater or less degree of unhealthy scrofulous suppuration. VI. Induration of the cerebral substance. Several exam- ples of this important affection have been already referred to under the first part of these Essays. I have there stated the grounds for believing, that it is the result of a slow inflamma- tory action; that it may continue for a very considerable time in a state of simple chronic inflammation, and then pass gra- dually into a state of induration: and, it is probable, that there is in some cases, formed around the diseased portion, a sac of coagulable lymph, giving it the appearance of a new formation embedded in the substance of the brain. In a state of simple induration, this disease may continue for a long time, producing urgent symptoms, and may at length be fatal by passing into suppuration, or without having suppurated. VII. Ossifications. Under this head are to be included both osseous projections from the inner surface of the cra- nium, and internal ossifications, which are commonly found in the dura mater, most commonly in the falx. They gene- rally appear to be formed of thin laminae of bone in the sub- stance of the membrane, and many cases of them are on re- cord which did not appear to have produced any symptoms in the brain. In other cases, however, they seem to produce urgent symptoms, especially when they are in the form of sharp spiculae, or have acute angles which are so situated as to irritate the brain or its membranes. In a case of this kind by Saviard, there was in the broadest part of the falx a small 330 ORGANIC DISEASES OF THE BRAIN. triangular piece of bone with very sharp angles; and, where the dura mater came in contact with these angles, it was livid and discharged pus. In another by La Motte, which was connected with epilepsy* the bony spiculae were directed against the pia mater; and in one by Van Swieten, there was an irregular piece of bone an inch long, and half an inch broad, in the substance of the cerebellum. VIII. Hydatids. This name has been applied to several affections of the brain, some of which do not appear to be really hydatids. Of this kind are the vesicles which are often met with in the choroid plexus; they seem to be merely the loose cellular texture of that organ, elevated into vesicles by a watery effusion; and in a case by Dr. Baillie, they could be injected from the veins. Real hydatids, however, do occur in the brain, as in a case which will be quoted from Zeder, in which there were numerous hydatids, one of them the size of an egg, and containing three small hydatids within it. Cysts containing a watery fluid likewise occur in various parts of the brain; but it is doubtful whether they are to be considered as hydatids. A woman mentioned by Bonetus, after a blow on the back of the head, had headach for a year t with constant vertigo, and then died apoplectic. In the sub- stance of the left hemisphere, there was a cyst the size of an egg, which contained a clear fluid. In a girl mentioned by the same writer, who died, on the 12th day, of a febrile dis- ease, which ended in coma, there was found, on separating the two hemispheres, a cyst which burst on a slight touch, and discharged limpid fluid to eight or nine ounces. Bonetus mentions other cysts of a still larger size, one especially at- tached to the nates and the infundibulum, which burst on taking it out, and discharged fluid to the amount of two pounds. The patient had complained of fixed pain in the vertex for four months. I was long inclined to doubt the accuracy of these accounts, and to suppose that, in such cases, the fluid had really been contained in the ventricles, until I received, throughmy friend Dr. Frampton, the remarkable case by Mr. ORGANIC DISEASES OF THE BRAIN. 331 Headington, to be afterwards described, in which a cyst was found in the left ventricle containing sixteen ounces of fluid. The affections now briefly described seem to include the principal modifications of the organic diseases of the brain. Others, however, are met with which do not properly be- long to any of these classes, such as the stony tumour in a case to be quoted from Schenkius, the bloody tumour of Rochoux, and the real fungus haematodes of the brain, of which there are some examples on record. Fungous protrusion of the cerebral substance itself, such as occurs after the opera- tion of the trephine, is occasionally met without any such cause. A man mentioned by Dr. Donald Monro, had a pulsating tumour over the left eyebrow, pressure on which produced'headach and giddiness. It increased in size, and after seven months he died lethargic. On inspection the tu- mour was found to arise from the anterior part of the left he- misphere of the brain, and to have made its way through the frontal bone. It was the size of a China orange; in its structure it resembled the medullary substance of the brain; and it appeared to be covered by the dura mater.* When we endeavour to trace the leading symptoms con- nected with these various states of disease, we do not find any uniformity, by which particular symptoms can be dis- tinctly referred to the various forms of the morbid affections; we can therefore attempt only a very general outline of the principal modifications of the symptoms, which are connected with organic disease of the brain. They appear to be chiefly referrible to the following heads. I. The first class is distinguished by long continued and severe headach, without any other remarkable symptom. The * Trans. Col. Phy. vol. i. 332 ORGANIC DISEASES OF THE BRAIN. pain varies very much both in its seat and in its severity; and one very remarkable character of the affection is, that the pain sometimes occurs in regular paroxysms, leaving intervals of comparative or complete relief. Some remarkable exam- ples have already been given of this in Cases LXXX. and LXXXVI., and others will be afterwards referred to. The pain is in some cases acute and lancinating, in others obtuse; and it is sometimes referred to a particular spot, as the crown of the head, or the occiput. In many cases it is accompa- nied by a violent throbbing, and this also may be general, or it may be referred to a particular part of the head, as the occiput or one temple. In the more violent paroxysms the pain is intense, obliging the patient to remain for a conside- rable time in one position, the slightest motion aggravating it to perfect torture; but the remissions from this severe suffer- ing are often so remarkable as to lead a superficial observer into the belief that it is merely periodical headach, or head- ach connected with dyspepsia. This latter supposition is also countenanced by the stomach being frequently much disor- dered, and by the more violent attacks being often accompanied by vomiting. The diagnosis, indeed, is sometimes difficult, but, by attention, it will be found that the duration and violence of the pain must lead to a suspicion that the complaint is something more than common headach, and that, though the stomach is at times disordered, yet that the headach is often most severe when no disorder exists in the stomach that can account for it. The patient generally cannot bear a warm room, the noise of company, or even the exertion of cheer- ful conversation, without being distressed and his headach increased; and the same effects are produced by wine and bodily exertion. He seeks quietness, coolness, and darkness; and in these respects; the disease differs remarkably from dyspeptic headach, which is commonly dissipated by exer- cise and cheerful company. Sometimes "the paroxysms are accompanied by vomiting, and sometimes by violent throb- bing in the head. If, along with these local symptoms, the ORGANIC DISEASES OF THE BRAIN. 333 face be pale and the pulse feeble, and if much active treat- ment has been employed without relief, we must suspect the presence of organic disease. The terminations of the cases of this first class are various; they may be suddenly fatal by convulsion, or more gradually by coma, or by gradual ex- haustion without either coma or convulsion. A very fre- quent termination is by the accession of chronic inflammation, terminating by effusion or otherwise. In Case LXXXIII. I have given an example in which there was a remarkable mass of organic disease attached to the falx, while no symp- toms had indicated its existence, until the occurrence of the symptoms of chronic inflammation a few weeks before death. II. In the second form, after some continuance of fixed headach, the organs of sense become affected, as the sight, the hearing, the taste and smell, and occasionally the intel- lect. The loss of sight generally takes place gradually, being first obscured, and after some time lost; and very often one eye is thus affected before the other is at all impaired. Double vision also occurs, which either may be permanent or occur at intervals. One remarkable case will be re- ferred to, in which the blindness took place rather suddenly, and, after it had continued for some time, sight was restored under the action of an emetic. It remained distinct /or an hour, and then was permanently lost. The intellect is fre- quently impaired in cases of this class, and sometimes the speech is lost. The morbid appearances present no unifor- mity ; in two of them there were tumours so situated, as di- rectly to compress the optic nerves; in another, a large tu- mour pressed upon the corpora quadrigemina; in a third, the disease was situated at the lower part of the anterior lobe; and in another, in which the right eye only was affected, it was in the substance of the left hemisphere, near the poste- rior part. In a case by Drelincurtius, the disease was an enlargement of the pineal gland; and in another, in which there was both blindness and deafness, a large tumour was situated between the brain and the cerebellum. 43 334 ORGANIC DISEASES OF THE BRAIN. III. The third class corresponds with the second in the pain and affections of (he senses, with the addition of paroxysms of convulsion. These may occur with some degree of regu- larity like epilepsy, or may take place only at particular pe- riods, when the disease seems to be aggravated, and to be combined with some degree of inflammatory action. Some- times the paroxysms have a resemblance to tetanus, and in others to slight apoplectic attacks. A case of this kind will be referred to, in which there was loss of sight, hearing, smell and speech, and at last of the power of deglutition. The cases of this class present the same varieties of mor- bid appearance as the former, and no peculiar character can be traced in them, which enables us to explain the di- versities of symptoms in the three classes, except in regard to those cases in which the disease was so situated, as di- rectly to compress the optic nerves. This seems invaria- bly to produce blindess; but, in other cases, it will appear that tumours corresponding in their situation, and nearly of similar size, were in some cases accompanied with blind- ness and convulsion; in others by blindness without con- vulsion; and in others by pain alone, without either of these affections. One case which will be referred to was remarkable from the circumstance, that the convulsions ceased when the lungs became affected, and did not return, the affection of the lungs being fatal. IV. The fourth class is distinguished by convulsion, without any affection of the senses, often with very little complaint of pain, and in general without that fixed and constant pain which occurs in the other classes. The con- vulsion in some cases appears under the regular form of epilepsy; in others, in more irregular attacks, occurring repeatedly for a short time, and then ceasing for a conside- rable interval. Sometimes violent paroxysms of headach precede or accompany the convulsions, and, generally, af- ter some time, the memory is impaired. The cases of this ORGANIC DISEASES OF THE BRAIN. 335 class may be fatal in one of the attacks of convulsion, or by coma of some days' continuance. The morbid appear- ances are very various. The most remarkable in the cases to be referred to were, tubercles in the cerebellum, an hydatid in the right hemisphere of the brain, induration of the pons Varolii or of the substance of the brain, and tumours and bony spiculae in various situations. An im- portant variety of the disease occurs, in which the convul- sion is confined to one side of the body. In one case of this kind, there was a tumour on the surface of the oppo- site hemisphere, and in another a portion of the opposite hemisphere was indurated; the former case was also re- markable from the long continuation of the disease, and from the weakness and diminution of size of the lower ex- tremity of the affected side. V. The fifth class leads our attention to a new set of symptoms, namely, the paralytic. These may occur in the form of hemiplegia, paraplegia, or paralysis of all the parts below the neck, and in some cases one limb only is affected. The disease is distinguished from the ordinary paralytic cases, by coming on more gradually; one limb, perhaps, or part of a limb being first weak, and the weak- ness extending very gradually, until it amounts to paraly- sis. In some cases, the paralysis is preceded by violent pain in the limb. The speech is generally affected, and in many cases the memory; there may be fixed uneasiness in the head, or headach occurring in paroxysms. In one case, there was blindness of one eye; in another, of both. In one, there occurred a convulsion, but not till an advanced period; in another, epilepsy for more than a year. The inspections exhibit tumours or indurations, variously situ- ated; in the cases of hemiplegia, on the opposite side of the brain; in those of paraplegia, in the cerebellum or tuber annulare. It must, however, be confessed, that the cases of this class, with paraplegia, are rather unsatisfactory 336 ORGANIC DISEASES OF THE BRAIN. from want of attention to the condition of the spinal cord. In several cases to be afterwards described, it will be found that though there was disease in the brain, the real cause of the paraplegia appeared to be in the spinal cord; and, perhaps, it may be considered as a point not yet ascertained, whether paraplegia ever arises from disease confined to the brain. VI. The sixth class calls our attention to a subject of much interest; a train of symptoms, which are referred to the stomach, but which really depend upon disease in the brain. In many of the cases of organic disease of the brain, the stomach is affected; but those to which 1 now al- lude, are remarkable from the affection in the stomach being the prominent symptom. In these there is often, through a considerable part of their progress, very little complaint of the head, or no complaint so fixed and urgent as to di- rect our attention to the brain as the seat of the disease. There is generally, however, some pain or weight in the head, sometimes occurring in paroxysms like periodical headach, or in paroxysms accompanied by vomiting, like what is commonly called sick headach. The pain is in- creased by exertions, external heat, passions of the mind, and stimulating liquors; there is generally variable appetite, bad sleep, oppression of the stomach, and frequent vomiting. The vomiting sometimes occurs in the morning, on first awaking, and sometimes at uncertain intervals, and very suddenly without any previous sickness. There are, in general, uneasy sensations referred to various organs, by which the nature of the disease may be disguised in its ear- lier periods; but, after a certain time, symptoms referrible to the head generally begin to appear, such as fits of loss of recollection, convulsive paroxysms, and affections of sight. After this stage of the disease, death may occur suddenly in an attack of convulsion, or it may be preceded ORGANIC DISEASES OF THE BRAIN. 337 by a train of severe suffering. In cases of this class, we must beware of being misled in regard to the nature of the complaint, by observing that the symptoms in the stomach are alleviated, by a strict regimen, or by treatment direct- ed to the stomach itself. If digestion be impeded from whatever cause, the uneasy symptoms may in this manner be alleviated; but no inference can be drawn from this source, in regard to the cause of the derangement. In the earlier periods of this affection, the diagnosis is indeed often very difficult. There is generally more permanent and fixed uneasiness in the head, than we should expect to find in a dyspeptic case, and the uneasiness is increased by causes which would probably be beneficial to a dyspeptic headach, such as activity and cheerful company. The pro- minent morbid appearances in cases of this class seem to be in the cerebellum. VII. The seventh class is distinguished chiefly by slight and transient affections of an apoplectic character, of which I have formerly given some remarkable examples. In some cases, it consists chiefly of an habitual giddiness, which makes the patient afraid to walk alone: in others, there are sudden attacks of loss of all muscular power without loss of recollection, which are soon recovered from. Sometimes there are attacks of perfect coma, which may occur at regular or at irregular intervals; the patient having, in some cases, such warning of their approach that he goes to bed before the attack. There is usually more or less unsteadiness of the limbs, and, generally, but not always, headach. In some cases there are affections of sight, and these may either be permanent, or occur in paroxysms; and in some cases, giddiness and loss of recollection are excited by bodily exertion, and go off on desisting from it. This imperfect outline of a most important class of dis- eases, I shall illustrate by a selection of cases in an Appen- 338 ORGANIC DISEASES OF THE BRAIN. dix, partly from my own observation, and partly from other authorities. From these will appear the extreme difficulty of fixing upon any general principles, or of refer- ring the particular character of the symptoms to any thing in the seat or nature of the disease. Tumours, for example, will be found under the first class, unaccompanied by any remarkable symptoms; while, under the other classes, tu- mours in the same situation, and of no larger size, were ac- companied by blindness, convulsions, or paralysis. It does not appear that these diversities depend either upon the size of the tumours, or, as far as we know at present, upon their particular structure. But these points remain to be investigated; particularly, what diversity of symptoms is connected with the nature of the tumours, and especially with their characters, as being tumours distinct from the cerebral mass, or as being indurations of the substance of the brain itself. In regard to the treatment of this class of diseases, there is little to be said. I am persuaded, however, that we ought not to consider them all as hopeless. Many of them have certainly their origin in inflammatory action, and, by the proper treatment, we have every reason to suppose that their progress may at least be impeded, and the life of the patient prolonged, as well as rendered more comfortable. The treatment will consist in keeping the system extreme- ly low, by evacuations and spare diet, cold applications to the head, issues or setons in the neck, and avoiding all causes of excitement. I conclude this part of the subject with the following important case, for which I am indebted to my friend Dr. Kellie of Leith. It illustrates, in a very striking manner, the nature of the symptoms which may exist with most extensive and remarkable organic disease of the brain. Case CXXXIII.—A medical gentleman, aged 56, of a ORGANIC DISEASES OF THE BRAIN. 339 cultivated mind and temperate habits, had been for some time liable to various ailments, which his medical friends considered as in a great measure hypochondriacal. The most defined complaints were occasional uneasiness in the site of the frontal sinus, and a very peculiar feeling of numbness in the point of the thumb. But his general health appeared good, and he was able to enter into all the usual enjoyments of life, having retired from practice, till he was one day seized, while walking, with sudden sickness and faintness. These were followed by some headach, and an obvious difficulty of articulation, or rather a difficulty in finding the expression which he wished to make use of. He was now treated by bleeding and the other usual means; but this peculiar loss of the recollection of words continued and gradually increased, so that he had greater and greater difficulty in recollecting the words which he meant to employ, but he had no difficulty in pronouncing them. His understanding, at this time, was quite entire; his pulse varying from 80 to 112. He was nearly confined to the house, but out of bed during the day; and all the usual remedies were employed in the most assiduous man- ner. After he had gone on in this way for several weeks, he began to have slight distortion of the mouth, and com- plained of numbness of the right arm, and soon after of weakness of the right leg. These symptoms gradually in- creased to perfect hemiplegia: and about this time, also, he entirely lost his speech. He was now confined to bed, but without coma. He had the perfect use of his sight and hearing, and, as far as could be judged, his understanding was entire. He died with symptoms of bronchitis in the ninth week from the first attack. Inspection.—The left hemisphere of the brain was found to be diseased throughout in a very singular manner. Some parts of the mass were indurated, others softened; and it presented a variety of colours, chiefly a rose colour; gray, and yellow; and the more diseased portions, were highly 340 ORGANIC DISEASES OF THE BRAIN. vascular. In some places there were distinct insulated masses, enclosed in vascular cysts; these were generally indurated, but some were softened, and they were of a rose or flesh colour passing into gray. The change from those parts which retained a natural appearance to these degenerated portions was abrupt, and marked by a rose co- loured line. These rose coloured portions were chiefly in the parts nearest the surface; in the central parts this passed into the yellow or the gray, and many portions were in a state of ramollissement. The whole left hemisphere, in fact, presented little else than a mass of concentric indura- tions and softenings of the various colours which have been mentioned. On the upper part of the hemisphere, the disease did not extend entirely to the surface of the con- volutions; but at the base of the anterior and middle lobes it extended to the surface, and at one place there was a well defined spot of superficial ulceration the size of a split pea. PART IV. OF THE DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. In its structure, the spinal cord is very analogous to the brain, except that it is more dense in its consistence. The membranes of the cord are usually divided into three, the dura mater, arachnoid, and pia mater; but as that which has been termed the arachnoid seems rather to be a kind of loose cellular texture, scarcely deserving a distinct name, it will answer every practical purpose to consider the mem- branes as two. I. The dura mater of the cord does not differ in struc- ture from that of the brain, except in varying considerably in thickness at different parts. The principal facts to be kept in mind in a practical point of view are, that it ad- heres very slightly to the canal of the vertebras by a very loose cellular texture, and that it adheres very intimately to the margin of the foramen magnum. In this manner a cavity is produced betwixt the membrane and the canal of the spine, which may be the seat of effusion, and which has no communication with the cavity of the cranium; on the other hand, the space betwixt the dura mater and the pia mater, or the immediate covering of the cord, commu- nicates freely with the cavity of the cranium, so that a fluid may pass easily from the one to the other, according to the position of the body. 342 DISEASES OF THE SPINAL CORD. II. The pia mater, or proper covering of the cord, is a membrane of a loose or cellular texture. It seems to be con- tinuous from the pia mater of the brain, is closely attached to the body of the cord, and furnishes a covering to the nerves which issue from it. III. The substance of the cord is firmer than that of the brain, but in other respects analogous to it; being distin- guished into cortical and medullary matter. It is divided into four columns, the two anterior of which take their ori- gin from the crura cerebri, and the two posterior from the crura cerebelli. The spinal nerves arise by two distinct roots from one of the anterior, and one of the posterior of these columns; and recent investigations have rendered it probable, that a diversity of function is concerned in this double origin, that is, that the posterior columns give origin to the nerves of sensation, and the anterior to the nerves of motion. A canal has been described in the substance of the cord, which is said to be a seat of serous effusion, and to communicate with the fourth ventricle. On the autho- rity of Portal, Senac, Rachetti, and others, we cannot doubt that such a canal has been observed; but it seems very doubtful, whether it exists in the healthy state of the parts. In Portal's case, it extended as far as the fourth dorsal ver- tebra, and would have admitted a common quill. It was full of serous fluid, by which the ventricles of the brain were likewise distended. By the ancients, much importance was attached to the spinal cord in convulsive and paralytic affections, but their speculations seem to have been in a great measure conjec- tural. A correct pathology of the cord appears to be of very modern date, and perhaps may still be considered as being in a very imperfect condition. In attempting a ge- neral outline of it, I shall satisfy myself with a simple re- MENINGITIS OF THE CORD. 343 cord of the best authenticated facts, which may be arranged under the following heads: I. Acute inflammation of the membranes, or meningitis of the cord. II. Inflammation of the body of the cord, terminating by ramollissement or suppuration. III. Serous effusion in the spinal canal. IV. Extravasation of blood in the spinal canal, or spi- nal apoplexy. V. Fungoid disease and thickening of the membranes. VI. Induration of the cord. VII. Compression of the cord by new formations within the canal, as tubercles, albuminous depositions, hydatids, and ossification of the membranes. VIII. Destruction of a portion of the cord. IX. Concussion of the spinal cord. X. Certain affections of the bones of the spine. SECTION I. MENINGITIS OF THE CORD. Of this remarkable affection, I am enabled to give the two following examples; for the second of which I am in- debted to Dr. Duncan. The other I did not see during the life of the patient, but I was present at the examination of the body. I shall merely relate the cases without founding upon them any general conclusions in regard to the charac- ters of the disease. Case CXXXIV.—A gentleman, aged 26, had been for several years liable to suppuration of the left ear. It usually discharged at all times a little matter, but the attacks of pam 344 MENINGITIS OF THE CORD. were followed by more copious discharges;—the pain on these occasions extending over the left side of his head, and often continuing for a week with much severity. In the first week of April, 1817, he was confined from his usual employ- ments by headach, which affected both the forehead and the occiput; he lay in bed only part of the day; his appetite was bad, and his sleep disturbed; but there was little or no fre- quency of pulse, and for a week the complaint excited little attention. About the end of the week, he complained of pain extending along the neck, and in the beginning of the second week the pain in the head nearly ceased, but the pain in the neck became more severe, and extended farther downwards along the spine. It continued for several days to extend far- ther and farther down, until at last it fixed with intense seve- rity at the lower part of the spine, and extended from thence round the body, towards the spinous processes of the ilia. From this .time he never complained of his head, and seldom of the upper parts of the spine; but he became affected with great uneasiness over the whole abdomen, and great pain and difficulty in passing his urine. From the violence of these complaints, his sufferings about the 15th became extreme; he could not lie in bed for five minutes at a time, but was gene- rally walking- about the house in a state of extreme agitation, grasping the lower part of his back with both his hands, and gnashing his teeth from the intensity of pain; he had no inter- val of ease, and was sometimes incoherent and unmanageable. On the 16th, he went to the warm bath, walking down three stairs, and into an adjoining street, with little assistance. After his return from the bath he thought himself somewhat re- lieved, but the pain soon returned with its former severity, accompanied by great pain in the belly, severe dysuria, con- fusion of thought, and some difficulty of articulation. The pulse was about 100, and the bowels were easily kept open by the ordinary medicines. On the 17th, the symptoms were unabated; his speech was considerably affected; there were convulsive twitches of his face, and difficulty of swallowing; MENINGITIS OF THE CORD. 345 some squinting also was observed, but it was not permanent; the pulse was from 120 to 130. At night he became easier after a bleeding from the arm, and lay in bed for some time. After a short time, however, he got up again, and continued till three o'clock in the morning, sitting up, or walking about his house delirious and unmanageable. About three o'clock, while sitting in a chair, he suddenly threw his head backwards with great violence, and immediately fell into a state of coma, in which he continued for two hours, and then died. No pa- ralytic affection had been observed in any period of the dis- ease, except the slight affection of his speech; no difficulty of breathing, no vomiting, and no convulsion except the twitches of the face on the 17th. The pulse had varied from 90 to 130, and was reported to have been generally small and ir- regular. The bowels were easily kept open, but the pain in the back was much increased by going to stool. Two days before his death he had several attacks of shivering. Du- ring his illness, much purulent matter had been discharged from the left ear, and an inflamed tumour had formed be- hind it. Inspection.—After the most careful examination, every part of the brain was found to be in the most healthy state. On taking out the brain, some gelatinous deposition was found under the medulla oblongata, and purulent matter appeared in considerable quantity, flowing from the spinal canal. The spine being entirely laid open, the cord was found with a coating of purulent matter, which lay betwixt it and its mem- branes. The matter was most abundant at three places; at the upper part near the foramen magnum, about the middle of the dorsal region, and at the top of the sacrum; but it was also distributed over the other parts with much uniformity. The substance of the cord was very soft, and in some places much divided into filaments. All the other viscera were healthy. Case CXXXV.—A woman, aged 22, had been for more 346 MENINGITIS OF THE CORD. than three weeks affected with pains of a rheumatic character, extending over every part of the body, when, on the 11th of April, 1820, she was received into the clinical ward, under the care of Dr. Duncan. She then complained of pain in the back of the neck and loins, and at the top of the right scapula; also of an acute pain in the right hypogastric region, increased by pressure and by inspiration. The head was considerably retracted, and could not be bent forward; the spine was bent backwards, and the muscles of the back felt contracted and rigid. She had alternate rigours and flushes of heat, great restlessness; pulse 148 and full; respiration 44, with some cough; tongue foul; bowels confined. She was treated by large bleeding, purging, warm bath, &c. On the 12th there was little change. On the 13th, she had difficulty of swal- lowing, and great restlessness; the spine was curved back- wards as before, and the bowels were obstinate, pulse 144. On the 14th, after free purging was produced, she seemed somewhat relieved, and could bring her head a little forward; but she said the pain was unabated. It was now chiefly re- ferred to the right shoulder, and the upper part of the chest, sometimes shooting into the right axilla. She had also pain in the lower part of the belly, and the abdomen felt distended and tense. She had less difficulty of swallowing, and was in- clined to sleep, but during sleep there was much subsultus; pulse 148 and small. On the 15th, the head was less re- tracted, and there was more power of moving it. The pains were abated, except in the abdomen; there was much subsul- tus and tremor; pulse 140; bowels open; tongue foul. She was much inclined to sleep, but quite distinct when roused. At night she was put into the warm bath, and expired in the bath. Immediately after death the muscles of the neck be- came entirely relaxed. Inspection.—There was some fluid in the ventricles of the brain; and, on the posterior edge of the right lobe of the cerebellum, there was a thread of coagulable lymph. The cervical portion of the spinal cord was healthy; the dorsal MENINGITIS OF THE CORD. 347 and lumbar portions were covered by a uniform thin coating of coagulable lymph of a greenish yellow colour, and soft con- sistence. It was chiefly on the posterior part, betwixt the cord and its membranes, and the membranes were remarka- bly vascular. Several cases have been described by Duchatelet and Mar- tinet, of inflammation of the membranes of the cord termi- nating by puriform deposition, but they were in general com- plicated with a similar disease in the membranes of the brain. The prominent symptoms, referrible to the spinal cord, were, pain extending along the spine, and tetanic contraction of the muscles of the back and neck, in some of them amounting to perfect opisthotonos. In one there was rigidity of the mus- cles of the left arm, with a convulsive twitching of the-thumb and fingers of both hands ; in another, there was a remarkable slowness of breathing, which was not above five in a minute. Ollivier, in his second edition, has described several inter- esting cases, which present the same general characters. The prominent symptom was, pain referred to some part of the spine increased by motion, and sometimes little complained of except upon motion; it in general extended along some of the limbs, and was accompanied by muscular rigidity or teta- nic spasms. Paralysis occurred in one case, but this seemed to depend upon a degree of ramollissement of the body of the cord. One of his cases was remarkable from the remissions of the symptoms in the first stage. There was an acute pain referred to the neck, which came on with intense severity at ten o'clock at night, and ceased at three in the morning. After seventeen days this ceased, and was succeed- ed by pain in the loins, which afterwards extended flong the back and into the inferior extremities; and was then ac- companied by muscular rigidity, and tetanic spasms of the legs, back, and neck. The patient at last died comatose; and the case seems to have gone on about five weeks. There was extensive deposition of pus and false membrane between 348 MENINGITIS OF THE CORD. the membranes of the cord at various places, especially in the lumbar region, where the matter had found an outlet be- twixt two of the vertebrae, and had spread* under the muscles. In another case, the symptoms were, at first, more obscure. There was an expression of suffering with a retention of urine, but no defined complaint, except that the patient screamed when his lower extremities were moved, and they became paralyzed without loss of feeling. There were afterwards rigidity and partial paralysis of the arms, rigidity of the trunk, and retraction of the head; and he died in ten days. Between the membranes of the cord there was an extensive deposition of false membrane and flocculent matter, in some places four or five lines in thickness. It was most abundant on the pos- terior surface of the cord, and towards its lower extremity; and there was some softening of the substance of the cord.* Inflammation of the parts surrounding the spinal cord may also be excited by external injuries, without any affection of the bones of the spine. A wagonner, mentioned by Mr. Charles Bell, sitting upon the shafts of his cart, was thrown off by a sudden jerk, and pitched upon the back of his neck and shoulders. He was carried to the Middlesex Hospital, where he lay for a week, without complaining of any thing except stiffness of the back part of the neck; he could move all his limbs with freedom. On the 8th day after his admission, he was seized with general convulsions and locked jaw. After a few hours, he was affected with a singular convulsive mo- tion of the jaw, which continued in a state of violent and in- cessant motion for about five minutes. This was followed by maniacal delirium. He then sunk into a state resembling ty- phus fever, and, after four days, was found to be paralytic in his lower extremities. " He lived a week after this, but con- tinued sinking, and still retained about him much of the cha- racter of typhus. The day before his death, he was perfectly sensible, and had recovered sensation in his legs." On dis- • Ollivier, Traits de la Moellc Epiniere et ses Maladies. Tome ii. 2d Edit. MENINGITIS OF THE CORD. 349 section, a great quantity of purulent matter was found within the spinal canal, which had dropped down to the lower part of it. It appeared to have been formed about the last cervi- cal and first dorsal vertebrae, and at that place, the interver- tebral cartilage was destroyed, so that the pus had escaped outwards among the muscles. In another case related by Mr. Bell, in which the last dorsal vertebra was fractured, purulent matter was found betwixt the spinal cord and its membranes. In this case there was no paralysis. The leading symptoms were fever, restlessness, vomiting, and high delirium; death took place.from sudden sinking.* To this place, perhaps, should be referred some notice of the appearance of increased vascularity of the cord or its membranes, and turgidity of vessels about the origin of the nerves. It constitutes the plethora spinalis of continental writers; and much importance has been attached to it as the cause of disease in many of the principal functions of the body. By exciting irritation at the origin of the various spinal nerves, it has been considered as the source of many obscure affec- tions of the thorax and abdomen; of tremor, convulsions, pa- ralytic affections, chorea, epilepsy, and tetanus. It has also been regarded as the seat of many of those painful affections of the back and the loins, which take place in connexion with haemorrhoids, menstruation, abortion, and continued fe- ver. These writers have speculated much on the changes ' which take place in the thoracic and abdominal viscera, so as to throw the blood with undue impulse upon the vessels of the spinal cord. Such determinations they suppose to take place from violent colics, suppressed menstruation, diseases of the liver, and continued fever.t It must, however, be con- fessed, that the morbid appearances, which are referrible to the head of spinal plethora, are extremely ambiguous; and * Quarterly Reports of Cases of Surgery, part 2. | See Frank, Oratio de Vertebralis Culumnx in morbis dignitate, Brera della Rachialgite, and Ludwig de Dolore ad Spinam Dorsi. 45 350 MENINGITIS OF THE CORD. there is little doubt that they are very much influenced by the position of the body after death; but it is due to the specula- tions of writers of high eminence, to give an example of the affections which they refer to this class. (1.) A man who died of peripneumony, had been affected in the course of his illness with numbness and loss of feeling in the lower extremities. On dissection, the arteries of that part of the spinal cord, which is included in the dorsal verte- brae, were found turgid with blood, as if they had been highly injected.* Portal refers to several other cases, which he ex- plains upon the same principle, and in which convulsive and paralytic affections of the extremities occurred in various in- flammatory diseases. (2.) An infant was attacked during dentition with convul- sions, which degenerated into epileptic fits. When he was five years and a half old, he had four or five fits every day, and became paralytic; he died at six years and a half. The spinal sheath appeared as if injected, and the medullary sub- stance was softened and of yellowish colour about the 6th and 12th dorsal vertebrae.! (3.) A young man, aged twenty-one, was affected with fe- ver and high delirium. When the delirium subsided, he had convulsive motions of the superior extremities, and soon after died comatose. On dissection, the vessels of the pia mater of the spinal cord, at its upper and posterior part, were found distended with blood, as if they had been highly injected. This was especially remarkable about the origin of some of the spinal nerves. There was a similar appearance on the pia mater of the brain, and some effusion on its surface.]: • Portal. Cours d'Anatomie Medicale, torn. iii. page 219. f Esquirol Bulletin de la Faculte de Medicine. \ Morgagni, Ep. x. INFLAMMATION OF THE SFINAL CORD. 351 SECTION II. INFLAMMATION OF THE SUBSTANCE OF THE SPINAL CORD. In referring to the inflammation of the substance of the cord, the appearances to be described under this section, I am guided by the analogy of the corresponding affections of the brain. I allude more particularly to the ramollissement, which seems to be one of the most common morbid appear- ances in the acute affections of the spinal cord, and which, in reference to the brain, I think has been distinctly traced to be a result of inflammation. I again leave this doctrine, however, to the judgment of the reader, and shall make no farther use of it here, than as a ground of arrangement. This important subject has not yet been investigated with that attention which it merits; but there is reason to believe, that inflammation of the substance of the cord, like the cor- responding affection of the brain, may terminate fatally in four different forms: I. In the inflammatory stage. II. By ramollissement. III. By undefined suppuration. IV. By abscess. § I.—Inflammation of the substance of the cord fa- tal IN THE INFLAMMATORY STAGE, WITH INCIPIENT RA- MOLLISSEMENT. This part of the subject is obscure, and the termination of the disease in the inflammatory stage may perhaps be con- 352 RAMOLLISSEMENT OF THE CORD. sidered as doubtful. The following is the only case that I find on record in any degree referrible to this head. A woman had long been subject to a convulsive affection in the left lower extremity, immediately before the appear- ance of the menses; this occurred at every period; when the discharge took place freely, it ceased. After the cessation of the menses, which happened at the age of 40, this extre- tremity became paralytic. After some time she was affected with convulsions of the left arm, and soon after died coma- tose. On dissection, the membranes of the spinal cord were found in a state of inflammation at some of the last dorsal vertebrae. The cord itself was very red and softened on the right side; on the left it was sound through its whole extent.* Lieutaud refers to a case described by Laelius a Fonte, in which death happened on the 14th day of continued fever, after paraplegia and suppression of urine; "in conspectum venit ren sinister, inflammatus et syderatus; laesa etiam erat medulla spinalis in eodem latere." § II.—Ramollissement or the cord. This remarkable affection will be illustrated by the fol- lowing important cases. In the first it was complicated with extensive inflammation of the membranes: the second shows the disease confined to the body of the cord; and the third is chiefly remarkable from its resemblance in the symptoms to an affection of the brain. The fourth shows the affection arising from an injury; and the fifth affords a very interesting example of the disease in a chronic form. Case CXXXVL— A gentleman, aged 18, of an un- healthy constitution, had suffered for several years from • Portal, Cours d'Anatomie Medicale, tome iv. page 116. RAMOLLISSEMENT OF THE CORD. 353 ulcers in various parts of his body, accompanied by exfo- liation of bone, especially from the leg, thigh, and sacrum. For several months before the fatal attack, he had a sore on his head with caries of the bone beneath, to the extent of a shilling or upwards. But he was in good general health, and was pursuing his studies at the University of Edin- burgh, when, on the 24th September, 1823, he consulted my friend Dr. Hunter, on account of sore throat with slight fever, which passed off in two days: and, on the three following days, he was going about in his usual health. On the 30th, he was again confined to the house, and com- plained of pain in his loins without fever. On the 2d of October, this pain had increased; it was chiefly seated among the lower dorsal vertebrae, and extended downwards in the course of the ureters, with frequent desire to pass urine. On the 3d, the urinary symptoms were gone, the pain was diminished in violence, and it was lower down, being now chiefly referred to the sacrum. On the 4th, he continued in the same state; he was entirely free from fever; the pain in the back was by no means severe, but as it was not removed, a blister was applied to it. (5th,) The pain of the back was removed, but he com- plained of pain of the belly, especially about the pubis; there was some dysuria, and a feeling of numbness on the inner side of both thighs. At night there was retention of urine requiring the catheter. (6th,) The numbness of the thighs was increased, with acute darting pains occasionally shooting along them, and complete retention of urine. (7th,) Perfect paraplegia of both thighs and legs with- out loss of feeling; retention of urine, and involuntary stools. The most judicious treatment had been employed without any benefit. (8th,) I saw him for the first time along with Dr. Hun- ter. There was now perfect paraplegia and complete re- tention of urine; pulse about 90 and soft. There was some 354 RAMOLLISSEMENT OF THE CORD. pain, which was referred to the lower part of the dorsal re- gion; there was no other symptom. Cupping on the back was employed, followed by another large blister, &c. (9th, 10th, and 11th,) There was no change, except that the pulse was becoming a little frequent. His mind was entire. Some pain of the back was at times mentioned, but it was not severe, and he made no other complaint. Perfect palsy of the limbs continued, and the numbness was extend- ing upwards upon the abdomen. (12th,) The numbness was extending upon the thorax; there was very little complaint of the back, but acute dart- ing pains were complained of extending along both arms. The sore on the head being examined, and the opening en- larged, the bone was found carious, and some matter was discharged from it by a very small opening. In conse- quence of this appearance, a perforation was made by a small head of a trephine, but no disease was found beneath the bone. In the evening, his pulse having become more frequent, farther bleeding was employed with relief. (13th,) No change; his mind was quite entire, and he made no complaint of any thing; stools involuntary. (14th,) The urine came off without the catheter, on rais- ing him up into an erect posture. Pulse frequent and fee- ble; strength sinking. He died in the night, having con- tinued quite sensible until about six hours before his death. There never had been the least attempt at motion of the lower extremities, but the sensibility remained. Inspection.—In the brain all was quite sound, except some old thickening of the dura mater in the neighbour- hood of the diseased bone. The bone was carious and very thin to the extent of a half-crown piece; around this por- tion it was thickened, especially on one side, where it was fully double the natural thickness. There was no effusion in the head, and no appearance of any recent disease. In opening the spinal canal some purulent matter flowed out during the sawing, from about the middle of the dorsal RAMOLLISSEMENT OF THE CORD. 355 region; and one of the vertebrae at that place was found con- siderably carious. The canal being opened, there was found most extensive deposition of flocculent matter, of a purulent appearance, on the outside of the membranes of the cord; it was most abundant for some inches about the lower part of the dorsal region, but likewise extended upwards to the fourth cervical vertebra. The dura mater of the cord being laid open, bloody sanious fluid was discharged from be- neath it; and the pia mater was found highly vascular. The substance of the cord was found most extensively destroyed in its structure along nearly the whole extent of the dorsal portion. The anterior columns of this part were completely disorganized and broken down into a soft diffluent pulp; on the posterior part, the cord more entire. When the whole cord was taken out and suspended, it hung together by the posterior columns of the dorsal portion, while the anterior part of it fell off entirely in a soft diffluent state. The parts above and below the diseased portion were quite firm and healthy. r Case CXXXVIL—A man, aged 56, in the last week of March, 1823, was much exposed to cold in travelling on the outside of a coach, after which, he was seized with pain of the right arm and leg, most severe about the shoulder, but affecting the whole side; and there was also considera- ble headach. He soon perceived some loss of power of the affected limbs, which began at the upper part of the arm and extended downwards so gradually, that he was able to write distinctly, after he had lost the power of raising the arm or bending the elbow. The leg then became affected in the same gradual manner, and after about tenor twelve days from the commencement of the disease, the whole leg and arm had become completely paralytic. Some pain con- tinued in the parts, and was sometimes severe, especially in the leg. About this time he was first seen by Dr. Mon- 356 RAMOLLISSEMENT OF THE CORD. crieffj who found the pulse 96, and rather sharp. He was quite sensible, and still complained of some headach, and of pain extending from the shoulder along the affected arm and leg. Repeated blood-letting, blistering, purgatives, &c. were employed, and the headach was removed. The other symptoms continued as before; the right leg and arm were completely paralytic, and sometimes very painful; pulse 84, and rather weak; his mind quite entire. He conti- nued in this state till about the 26th of April, when the left arm became paralytic rather suddenly: it did not how- ever become so completely motionless as the limbs of the right side, and the left leg was not at all affected. The pulse was now feeble, and his general appearance expressive of exhaustion. I saw him first about this time. There was slight delirium, which however passed off again; and he continued quite sensible and even cheerful, without any pain, except occasionally in the right leg, till the 7th of May, when he became again delirious; the pulse 120, and weak. On the 8th, he lay in a state of stupor, muttering incoherently, but answering questions distinctly when he was roused. He died on the morning of the 9th, having lost his speech a few hours before death. For the last eight or ten days there had been extensive gangrene on the sa- crum. Inspection.—Every part of the brain was found in the most healthy state. Much bloody fluid was discharged from the spinal canal into the cavity of the cranium before the spine was laid open. On laying open the spinal canal, the cord was found in a state of complete ramollissement, from the second to the last cervical vertebra: the parts above and below were quite healthy. . The following case shows the disease running its course with much greater rapidity, and with a different train of symptoms. RAMOLLISSEMENT OF THE CORD. 357 Case CXXXVIII.—A boy, aged seven, had been indis- posed from the 18th to the 20th of May, 1823, but so as to attract little notice. There had been some headach and slight feverishness, for which he took purgative medicine, and on the morning of the 22d he seemed almost well. About two o'clock in the afternoon of that day, he was seized with severe and general convulsions. I saw him soon after this, and found him confused, incoherent, and partially comatose; the pulse 60 and weak; face pale; the bowels were slow, and some worms had been passed. The usual remedies were employed with little effect. (23d,) In the morning he was partially comatose, the eye fixed and insensible. In the course of the day he be- came less comatose, but incoherent, with much talking and Bcreaming: complained of headach, and was impatient of light. In the evening there was slight appearance of squint- ing, and in the night some convulsions; pulse very variable, being sometimes rapid, and sometimes slow; the bowels were very obstinate, but yielded to repeated doses of cro- ton oil. (24th,) Seemed much better—eye natural,face pale, pulse 120, bowels kept open by the croton oil. He was quite sensible, and said there was still some headach, but did not appear to suffer; he continued in this favourable state until early in the morning of the 25th, when the convulsions re- turned with much severity, after which he sunk into a low oppressed state, and died early in the afternoon. Inspection.—There was no effusion, and no appearance of disease in the brain. On removing the brain, a considerable quantity of fluid flowed from the spinal canal; and on laying open the canal there was still a good deal found between the cord and the external membrane. The cord was healthy at the cervical portion, but in the upper part of the dorsal region it was remarkably softened and broken down lh,s appearance extended for several inches, but varied in degree. 46 353 RAMOLLISSEMENT OF THE CORD. At one place a complete separation took place, in attempting to raise the cord, the part falling down into a soft diffluent pulp through its whole diameter. From the middle of the dorsal portion it was quite firm and healthy. The inner membrane of the cord was dark-coloured, highly vascular, and showed evident marks of inflammation, at the part cor- responding with the softened portion of the cord. The following case (for which I am indebted to Dr. Hun- ter) shows this affection arising from an external injury, with- out any affection of the bones of the spine. Case CXXXIX.—A man, aged 36, in August, 1827, was thrown from the top of a wagon, a height of about ten feet. lie alighted upon a pile of small stones, in such a manner, that the shock, on first coming in contact with the top of the pile, was received on his back, between the shoulders. He attempted immediately to get up, but fell instantly, from com- plete loss of power of the lower extremities; and very soon after, he had involuntary discharge of urine and feces. He was conveyed home in this state, but little appears to have been done for him except the application of sinapisms; and it was about a month after the accident, when he was re- ceived into the Infirmary of Edinburgh under the care of Dr. Hunter. He was then considerably emaciated, and there was complete loss of motion of the lower extremities, without loss of feeling, and all the muscles of the affect- ed parts were in a remarkable state of flaccidity. He com- plained of deep-seated pain on pressure in the region of the third, fourth, and fifth dorsal vertebrae. He had liquid stools which were discharged involuntarily. His urine was at first discharged involuntarily, mixed with much viscid mucus; af- terwards it became obstructed, apparently from the viscidity of the mucus impeding the passage, and he then required the catheter. His breathing was very slow, being generally, when he was asleep, about nine in a minute; and when awake RAMOLLISSEMENT OF THE CORD. 359 about thirteen. His pulse and other functions were natural; his appetite was moderate, and his digestion good; his mind was quite entire. On the third day after his admission, he began to complain of pain in the temporal and masseter mus- cles, with inability to open the jaw; and this rapidily increased to perfect trismus. He then had emprosthotonos, and the usual tetanic symptoms; the abdominal muscles being very tense and hard, and the body considerably bent forward. On the following day more general spasms took place, affecting the arms and face, and the muscles about the neck and throat, with great difficulty of swallowing. The spasms now as- sumed the form of opisthotonos. He died in the night, about forty-eight hours after the first appearance of the trismus. All the usual remedies had been employed in the most active and judicious manner without benefit. Inspection.—No injury could be detected in any of the bones of the spine. There was a high degree of vasculari- ty of the pia mater of the cord, especially at the upper part of the dorsal region. There was most extensive ra- mollissement of the body of the cord, which affected chief- ly the anterior columns. These were most remarkably softened throughout almost the whole course of the cord, in many places entirely diffluent, and the softening was traced quite to the upper part of the cord, and affected the corpora pyramidalia. The posterior columns were also softened in many places, though in a much smaller degree, not diffluent like the anterior, but breaking down under very slight pressure. A remarkable modification of the disease occurs, in which, although it is seated in the upper part of the cord, the symptoms appear only in the superior extremities and ad- joining* organs, without any affection of the lower parts of the body. A gentleman mentioned by Ollivier, who was liable to epilepsy, complained first of uneasiness in the throat, with difficulty of swallowing, accompanied by an 360 RAMOLLISSEMENT OF THE CORD. acute pain in the nape of the neck, and lower part of the occiput, and speedily followed by fever, difficult breathing and vomiting. He then had numbness of the left hand, which rapidly extended along the arm; the right was im- mediately after affected in the same manner, and on the following day they were both paralytic. His legs were not in the least affected, nor the functions of the bladder or the bowels. There was at last increase of dyspnoea with extreme difficulty of swallowing, while nothing could be seen in the throat, and he died on the eighth day, having preserved his intellects to the last. There was extensive ramollissement of the upper part of the cord, chiefly seated in the gray matter, which was of a rose colour, with a highly vascular state of the membranes connected with the part; there was extensive effusion in the spinal canal, and some extravasated blood in the cellular tissue between the vertebrae and the dura mater of the cord. The lungs were dense and loaded with blood, and there was increased vascularity of the bronchial membrane. In another case, with extensive ramollissement at the upper part of the cervical portion, there was palsy of all the extremities. The only difference in the morbid appearances, betwixt the two cases, seems to have been, that the ramollissement in the former was chiefly seated in the gray matter, while in the latter it extended nearly through the whole thickness of the cord. Ollivier has also described several cases which followed a course similar to Case CXXXVIII. being fatal in about three days, with violent convulsion without pa- ralysis. The disease occurs in a more chronic form, in which it may go on for a considerable time, sometimes for years, before it is fatal. There is generally in these casea some uneasiness in the back, with paralytic symptoms, begin- ning in a part of a limb, and in a slight degree, and ad- vancing very gradually to confirmed palsy. The lower RAMOLLISSEMENT OF THE CORD. 361 extremities are most commonly affected, but in some cases the arms only, and in others all the limbs. There is some- times permanent contraction of the affected limbs, and sometimes there are spasmodic affections of them; and the disease may go on in this manner for years, and at last be fatal by ramollissement. This form will be illustrated by the following case, which I saw along with Dr. Alison. Case CXL.—A gentleman, aged 42, in October, 1827, began to be affected with pain in the lower part of the back, stretching round the abdomen, and frequently shoot- ing into the groins. After a short time this was succeed- ed by coldness and numbness of his feet, which gradually extended upwards with diminished power of motion, until, after several weeks, it terminated in perfect loss of motion of both lower extremities, with retention of urine. There was pain in some parts of the affected limbs, and in others a painful sensation of cold. This perfect loss of power , continued five or six weeks, when, after a great deal of * treatment by cupping, blistering, &c. he recovered a slight degree of motion, but no power of the bladder. He then began to be affected with spasms of the muscles of the back and abdomen, with a very uneasy sensation of tight- ness across the abdomen, and at times across the lower part of the thorax. The spasms occasionally assumed the cha- racters of opisthotonos, and at one time he had almost in- cessant hiccup, which continued in a most violent degree for several days. After the employment of various anti- spasmodics, this subsided under the use of musk. During the course of these symptoms, he frequently complained of pain in various parts of the spine, at first in the lower part, and afterwards higher up; and the feeling of numbness ex- tended gradually upwards, till it reached nearly the upper part of the dorsal region, and was felt in a very considera- ble degree along the sides of the thorax. 362 RAMOLLISSEMENT OF THE CORD. After this he became liable to feverish attacks at night, terminating in the morning by very profuse perspiration; but this was strictly confined to the parts which were not palsied, and there never was the smallest moisture on the lower extremities. He had also, in the upper extremities, a frequent feeling of intense heat, while the lower conti- nued cold and benumbed. During this time a considera- ble but very imperfect degree of motion continued in the lower extremities, but the bladder continued entirely pa- ralytic. In April, 1828, he went to the country, and at this time he had such a degree of motion as to walk a little on a smooth garden walk, leaning on two persons, or supported by crutches. But soon after this he began to complain of pain in the head. It occurred in irregular paroxysms, and was often referred to a small defined spot, on various parts, especially behind the ear, and sometimes to the tip of the ear. This pain seemed to abate under the use of arsenic; but soon returned, and became more fixed and permanent, and the palsy of the limbs again increased. After an ab- . sence of about two months, he returned to town in the be- ginning of July. At this time the headach was severe, and the power of the limbs so much impaired, that he was entirely confined to bed. In a few days after his return, the right arm became paralytic, and his speech considerably impaired. After a day or two, these symptoms rather sub- sided, but in the following night he became comatose, and died in the afternoon. Tliere never was complete loss of sensation of the affected limbs; he had only complained of it occasionally at particular spots, and of a general feeling of numbness and coldness. Inspection.—There were some scales of bone attached loosely to the inner surface of the dura mater of the spinal cord. The whole cord was of a pale rose colour, and in a state of complete ramollissement through its whole extent, being in every part entirely diffluent. The medulla ob- RAMOLLISSEMENT OF THE CORD. 363 longata was tolerably healthy, except a slight degree of softening on its anterior part; and there was also a degree of softening on the tuber annulare, which seemed to involve the origin of the fifth nerve. Beyond this, the ramollisse- ment became again more decided, extending along the crura cerebri and cerebelli, and considerably into the substance of the brain, at the part adjoining the crura. The brain, in other respects, was healthy, and there was no effusion in the ventricles. It is difficult to trace the precise nature and progress of the affection of the cord, when the disease advances in so gradual a manner as in this case, and terminates in disorga- nization so complete and extensive. In tracing the history of the analogous disease of the brain, we found reason to believe, that it is originally an inflammatory affection of a low chronic character, seated in a small part of the cerebral substance; that it may continue for a considerable time in the state of simple inflammation, and then subside; or that it may terminate by a permanent change in the structure of the part, generally with some degree of induration. In this state we find it when the patient dies of another disease, as in Case CXXVIII. When it is itself the fatal disease, it seems to be so by passing either into ramollissement, or into partial and unhealthy suppuration. It is probable that the same character of disease takes place in the spinal cord; and it is found, in the same manner, sometimes in a state of ramollissement, sometimes in the state of induration, and sometimes one part is found indurated and another softened. In a remarkable case communicated to Ollivier by Andral, the affection began with numbness of the forefinger of the left hand, which gradually extended over the hand and arm. After some time the other hand and arm became affected in the same manner, and, after a year, the lower extremities. All the limbs then became paralytic, with permanent con- traction, but without loss of feeling. The legs were bent 364 RAMOLLISSEMENT OF THE CORD. upon the thighs, and the thighs upon the abdomen, and the arms rigidly fixed across the thorax, with the points of the fingers pressed against the palms of the hands. If attempts were made to move the limbs from these positions, they were thrown into spasmodic contractions with much pain. The patient died in this state at the end of eight years from the commencement of the disease. Along nearly the whole length of the cord, there was a central cavity full of a soft gray mucus. It was considered as arising from ramollisse- ment of the gray central matter of the cord, and the parie- tes of the cavity were formed by the white matter in a healthy state. In a case by Ollivier, in which palsy took place in the same gradual manner, but affected only the lower extremities, the patient was confined to bed for seven years. His legs were drawn up upon his body, and were en- tirely motionless, but preserved their feeling. There was ex- tensive ramollissement of the anterior pillars of the cord: and a very remarkable circumstance was, that the softening was greatest in the upper parts of the cord, the corpora py- ramidalia, and several parts of the brain, and became less towards the lumbar portion. The intellectual faculties had been almost entirely obliterated, but the motion of his arms continued entire to the last. Such are the difficulties and obscurities of this interesting subject. A different course of symptoms occurs in a remarkable case described by M. Rullier.* A gentleman, aged 44, who had slight curvature of the spine at the upper part, was seized with pain in the curved portion, which, after several remis- sions, increased rapidly, and was followed by sudden and complete palsy of both his arms. They became rigid, con- tracted, and entirely motionless, and the points of the fingers were forced against the palms of the hands. The sensibility of the parts was not impaired, and the lower extremities were * Journal de Physiologic, 1823. RAMOLLISSEMENT OF THE CORD. 865 not in the least affected, for the patient could walk about without difficulty. He lived six years in this state, and died of pectoral complaints. A portion of the cord, six inches in length, occupying two-thirds of the cervical portion, and part of the dorsal, was entirely diffluent, so that before the mem- branes were opened, it moved upwards and downwards like a fluid. The posterior roots of the nerves of this portion preserved their nervous matter, i$ their junction with the membranes of the cord, but in the anterior roots it was des- troyed, and they were reduced to an empty neurilema. Se- veral other cases are mentioned in the same journal, intended to show the separate origin of the nerves of sensation and mo- tion from the different parts of the cord. In one case, there was loss of power of the whole body without loss of sensi- bility, and the disease was in the anterior part of the cord. In another, there was complete palsy of the legs, and partial palsy of the arms, while the sensibility was every where morbidly increased. The medullary matter of the cord was singularly contracted in volume. The anterior part of its upper half was of a reddish-brown colour, and as it were macerated; the roots of the nerves inserted there were so wasted as to be scarcely discernible, while the posterior roots weie preternalurally large. A case mentioned by Ollivier seems to establish the in- flammatory origin of the ramollissement of the cord, and at the same time shows the insidious and dangerous nature of injuries of the spine. A man having suffered an injury of the le by a fall, ten months after the accident had prickling of HA lower'e^-iij, which ceased after amont.lea,vmg it naralvtic The right lower extremity became affected in Skinner; an&d some projection of the vertebne at he afflcted part was then first observed. He had afterwards ;:rfr:^ tcr, betwixt the bone and the membranes of the cord at 47 366 RAMOLLISSEMENT OF THE CORD. affected part; and the portion of the cord included in the dis- eased membrane was entirely diffluent like cream. Above and below this portion, the cord was of a natural consistence, but highly injected, and of a deep red colour, especially be- low the softened part, where the redness was intense. I shall conclude this part o£ the subject with the following very remarkable case, for jvhich I am indebted to Dr. Moli- son. I did not see the patient during his life, but was pre- sent at the latter part of the inspection of the body, when the spinal cord was examined. I shall simply relate the case without entering upon any of the very interesting reflections which might naturally arise from it. Case CXLI.—A street porter, aged 37, since February 1827, had frequently complained of pain in his back, and in both sides of the thorax, with difficulty of breathing when making any great exertion. For a month before his death the pain of his back had been more severe, and he had great difficulty of swallowing. His general health, however, was very little impaired; and on Monday, 15th July, he carried a burden to Newhaven, 3 miles from Edinburgh, and afterwards went into the sea to bathe. While he was in the sea, as he after- wards stated, he became very confused, and, on attempting to come out, fell among stones. When he was taken up, he was bleeding profusely at the nose and mouth; and, after he was carried to an adjoining house, he vomited blood in large quantities. Through the following night he was restless and partially insensible, and talked incoherently ; he had several attacks which were represented as convulsive, in which his eyes became fixed, and there was much tremulous motion in his legs, but without any motion in his arms, which appear to have become paralytic at an early period of the attack. On the 16th he was first seen by Dr. Molison; immediately before his visit, he had brought up a large quantity of blood, which ran from his mouth in a full RAMOLLISSEMENT OF THE CORD. 367 stream, and then coagulated. He was somewhat lethargic, but distinct when roused; and complained of pain in his head, chest, and bowels. His head and his legs were in almost constant motion, but his arms were paralytic, being entirely deprived both of motion and feeling. His breathing was easy; his pulse frequent and small; countenance pale and anxious; and he had involuntary discharge of urine. In the evening, he again vomited blood in considerable quantities. (17th,) There was little change, except that he recovered the power of the bladder; perfect palsy of the arms continued, but his legs were in almost constant motion. There was no return of the vomiting of blood through the day; at night he fell asleep, and slept quietly for some hours, when he awoke quite sen- sible ; but, soon after, was seized with vomiting of blood to a great extent, and died almost immediately. Inspection.—The heart and lungs were healthy; the stomach contained a very large and firm mass of coagulated blood, which entirely filled it, and extended into the duode- num. In the descending aorta, about the 4th and 5th dorsal vertebrae, there was an aneurism the size of an orange, which had burst into oesophagus by a large opening. The 3d, 4th, and 5th dorsal vertebrae were extensively carious in their bo- dies, where the substance was destroyed to the depth of a quarter of an inch. On opening the spinal canal, some bloody albuminous-looking matter was found betwixt the bone and the dura mater of the cord, and between the dura and pia mater of the cord, there was a considerable quantity of a tena- cious sanious bloody matter, which covered the surface of the pia mater, from about the 2d or 3d to the last dorsal vertebrae. The substance of the cord, from about the 3d to the last dor- sal vertebra, was of a yellowish colour, and in a state of ex- tensive ramollissement, especially about the centre of this space, where it was entirely diffluent. On removing the cord the anterior part of the spinal canal, viewed from behind, presented several places where the bones were denuded of their covering and carious. This was most remarkable about the 3d, 4th, and 5th dorsal vertebrae. 368 UNDEFINED SUPPURATION OF THE CORD. § III.—Undefined suppuration of the cord. It may perhaps be doubted, whether some of the cases which 1 have referred to this head, ought not rather to be re- ferrible to the ramollissement. These two morbid condi- tions were not accurately discriminated till lately; but in the brain there seems every reason to believe that they are entirely distinct; and it is probable that they may likewise be so in the cord. 1. A woman, aged 23, who had suffered considerably from syphilis, was seized with severe quotidian intermittent, which proved very tedious, and resisted all the usual remedies. After some time, it was accompanied by pain in the lumbar region, diarrhoea, tormina, tenesmus, general debility, and emaciation. About three months after the commencement of the fever, she began to be affected with weakness and con- vulsive motions of the left lower extremity, resembling chorea. In walking, the leg was dragged, and, if she attempted, by a strong effort, a greater degree of motion, it was thrown into convulsive distortions. Soon after, the left arm became af- fected in the same manner, and there were also convulsive motions of the face and eyes. The complaint in the bowels now ceased, but the other symptoms increased, and the af- fection of the limbs soon amounted to nearly complete para- lysis. She was then affected with difficulty of articulation, and diminution of memory; and these soon terminated in loss of speech, coma, and death, which was preceded by general and terrible convulsions. Her death happened rather more than a month after the commencement of the convulsive af- fection of the leg. On dissection, some serous effusion was found in the thorax, and in the ventricles of the brain. The spi- nal cord was soft and flaccid, and to a considerable extent sup- purated. Its investing membrane was in many places covered UNDEFINED SUPPURATION OF THE CORD. 369 by a puriform fluid; and there was also serous effusion in the spinal canal.* 2. A young soldier, who had lately recovered from a pe- techial fever, was affected with pain in the dorsal vertebrae, difficulty of moving the lower extremities, retention of urine, involuntary discharge of feces, general debility and emacia- tion. A variety of treatment was employed for several months without relief. The weakness of the lower extremities in- creased to perfect paralysis; and, soon after, the superior ex- tremities became affected in the same manner. He then lost his speech, and, after lying a fortnight in this state, com- pletely immoveable and speechless, but in possession of his intellectual faculties, he died suddenly. On inspection, there was found no trace of disease in the brain, the thorax, or the abdomen. The spinal canal was inundated by a large quan- tity of sanious fluid. The cord itself was suppurated, dis- solved, and disorganized, at the lower part of the dorsal re- gion ; above this, it preserved its figure, but was very soft. Its investing membranes, and the periosteum lining the canal of the vertebrae, were destroyed at the part where the cord was so much diseased; but the vertebrae and their ligaments were sound.* 3. A man, aged 40, was received into the hospital of Cre- ma, in the spring of 1804, with no other complaint than ge- neral weakness and depression, for which no cause could be assigned. He lay constantly in bed, but did not complain of any pain; his appetite was good; and he was free from fever. From being lean and pale, he became so fat and ruddy that suspicions were entertained that he was feigning; but as win- ter approached, he became lean and cachectic. In Febru- ary, 1805, he became completely paralytic, both in his legs and arms; and he died suddenly in March. On inspection all was sound in the head, the thorax, and the abdomen. In * Brera Delia Rachialgitc, cenni patologici. In Atti dell' Accad. torn. i. 370 ABSCESS OF THE CORD. the spinal canal there was much effusion of bloody sanious fluid, with marks of inflammation and suppuration in the spi- nal cord, the substance of which was remarkably soft, and tending to dissolution.* § IV.—ARSCESS OF THE CORD. A woman, aged 56, was affected with sudden loss of power of the limbs of the left side, without loss of feeling. It soon amounted to perfect palsy; her voice became feeble, and her speech embarrassed; pulse natural; respiration quick. The left arm became cedematous. After four days the speech could not be understood; pulse feeble; increasing debility; stertorous breathing; and she died in a week. Inspection.—The brain was sound, but the pia mater was injected. In the centre of the right column of the spinal cord, in the middle of the cervical portion, there was a cavity three inches long, and two or three lines in diameter. It was full of a soft matter like pus, which became more consistent to- wards the parietes of the cavity. It seemed to be the gray substance pf the cord converted into pus. The parietes of the cavity were firm, and about a line and a half in thickness, and were formed by the healthy white matter. In the left column of the same portion of the cord there was a similar disease, but less extensive, being about one inch long, and one line in diameter; and its contents were less purulent, ra- ther resembling ramollissement of the substance of the cord. The membranes of the cord were hardened at the part, and also at a part in the dorsal region.t * Brera, ut supra. | Velpcau Kcvue Mcdicale, 1826. SEROUS EFFUSION IN THE SflNAL CANAL. 371 SECTION III. SEROUS EFFUSION IN THE SPINAL CANAL. I place this appearance by itself, abstaining from any hy- pothetical speculations in regard to the origin of it. I have already alluded to the ambiguity which attends serous effusion when it occurs between the dura mater and the inner mem- brane of the cord, on account of the free communication which this space has with the cavity of the cranium, or at least with the cellular texture of the arachnoid of the brain. When the effusion is contained in the cavity formed betwixt the dura mater and the canal of the vertebrae, there can be no doubt of its connexion with disease of the spinal canal. The following is the most distinctly marked case of this af- fection that has occurred to me. Case CXLII—A strong healthy child, aged nearly 2 years, after having been oppressed and feverish for two days, was seized with violent convulsion. The first fit continued about an hour, and left her comatose with distortion of the eyes. She had not recovered out of this state when she had another attack of convulsion, about two hours after the first. During the fits, and for some time after them, there was violent and irregular action of the heart, and a peculiar spasmodic action of the diaphragm. The second fit left her in a state of coma from which she never recovered. She took food or medicine when they were put into her mouth, but showed no other ap- pearance of sensibility. The eye was completely insensible and the pulse very frequent. She had afterwards several slight attacks of convulsion, and one more severe a short tune 372 SEROUS EFFUSION IN THE SPINAL CANAL. before death, which happened thirty-three hours after the first attack. Inspection.—No disease could be detected in the brain, except some appearance of increased vascularity, and slight effusion under the arachnoid. The brain and cerebellum being removed, there was a copious discharge of bloody fluid from the spinal canal. The canal ueing laid open, there was found a copious deposition of colourless fluid, of a gelatinous appearance, betwixt the canal of the vertebra? and the dura mater of the cord. It was most abundant in the cervical and upper part of the dorsal regions. Between the membranes of the cord there remained a small quanti- ty of the bloody fluid which had flowed into the cavity of the cranium. The substance of the cord, at the upper part, seemed softer than natural and very easily torn. All the viscera of the thorax and abdomen were perfectly healthy. The foramen ovale was pervious by a small opening. The effusion on the outside of the dura mater, in this case, was fairly to be considered as a distinct disease of the spinal canal; but the other effusion betwixt the mem- branes, though somewhat more ambiguous, is not to be overlooked, especially if we should find that this fluid is bloody, while the effusion under the arachnoid of the brain is colourless. In a child, aged between 3 and 4 years, mentioned by Ollivier, who died with symptoms of opisthotonos, diffi- cult deglutition, and coma, he found deposition of a red and very consistent fluid, in the cellular texture between the dura mater of the cord and the canal of the vertebrae in the dorsal region, serosity within the membranes, and the arachnoid of the cord covered with an albuminous con- cretion for four inches. The following cases are given by the eminent writers SEROUS EFFUSION IN THE SPINAL CANAL. 373 whose names are annexed to them, as examples of diseases depending upon serous effusion within the spinal canal. 1. Morgagni mentions a man, aged 40, who was affected with acute pain and weight in the lower dorsal vertebrae, the pain occasionally extending upwards or downwards to the top and bottom of the spine. After eleven days he was seized with paralysis of the right lower extremity, and in three days more with retention of urine. The pain was now so acute as to prevent him from lying down, and was soon after accompanied by dyspnoea, vomiting, and tonic convulsions of the trunk and arms, which recurred at intervals, and continued for about fifteen minutes. The left inferior extremity then became paralytic, and he died suddenly; his intellectual faculties had continued entire, except during the paroxysms of convulsion. On inspec- tion much fluid was found in the cavity of the spine, but the cord was sound; there was also fluid on the surface of the brain, but none in the ventricles.* 2. A child, aged 12 months, whose case is briefly re- lated by M. Chevalier, after appearing to be in much pain, lost the use of the inferior extremities, and died in three days. The spinal canal was found full of bloody serum, t 3. Bonetus mentions a young woman who, after suffer- ing severely from colic, fell into paralysis. It began at the upper part of the arms, and extended gradually to the points of the fingers. Afterwards the legs became affect- ed, and she died of gradual exhaustion a year after the first appearance of paralysis. Through the whole extent of the spinal cord, there was a space betwixt its dura and pia ma- * Morgagni de Causis et Scdibus, &c, Epis. 10. Sect. + Med. Chir. Trans, vol. iii. 48 374 SPINAL APOPLEXY. ter, full of serous fluid. There was also some effusion on the brain.* 4. A man mentioned by Portal had numbness of the in- ferior extremities, followed by paralysis of them, and ex- tensive oedema. After some time the arms became affect- ed in the same manner, and the cedema extended over the whole body. He died comatose. On inspection much fluid was found both in the brain and in the spinal canal. In the centre of the spinal cord there was a canal into which a large writing quill could be introduced. It was full of serous fluid, and extended as far as the third dorsal vertebra. SECTION IV. SPINAL APOPLEXY, OR EXTRAVASATION OF BLOOD IN THE SPINAL CANAL. Case CXLIII.—A child, aged 7 days, 1st September, 1818, was observed not to suck, and appeared as if he were prevented by something which impeded the motion of his tongue. Through the following day he cried frequently, and still did not suck; in the evening he was seen by Mr. White, who found the jaw clenched by spasm, but by very little force it could be opened. On the third day he was seized with convulsion, which recurred at various intervals, sometimes in the form of tonic spasm of the whole body, and sometimes of violent convulsive agitation. On the fourth the convulsion continued, and he died in the afternoon. * Boneti Sepulchretum Anatomicum, torn. L SPINAL APOPLEXY. 375 Inspection.—No disease could be detected in the brain. In the spinal canal, there was found a long and very firm coagulum of blood, lying between the bones and the mem- branes of the cord on the posterior part, and extending the whole length of the cervical portion. This is the only case that has occurred to me of this re- markable affection; but, as it appears to be uncommon, and to present some very interesting phenomena, I am in- duced to add the following examples. 1. A lady, aged 40, had headach and pain of the back; after a few days the pain of the back became very acute, and violent convulsion took place, which was fatal, after continuing five or six hours. All was sound in the brain, but extensive extravasation of blood was found in the spinal canal, which was most abundant about the 6eat of the pain.* 2. A gentleman, aged 61, had just arrived in Paris, from a long journey, when he complained of pain of his back, extending from the cervical vertebrae quite to the sacrum. After a few hours he was seized with paraplegia, and in- continence of urine and feces; and he died while the phy- sician was talking to him, who had been sent for on the oc- currence of the palsy. There was extensive extravasation of blood in the spinal canal, under the membranes of the cord. At the lower part it formed a mass like a bouillie of bullock's blood, in which the substance of the cord could not be distinguished, as far as the third dorsal verte- bra; and above this, where the cord was entire, it was of a deep red colour, and very soft.t 3. A young lady, aged 14, had headach, and pain in the back, with a tendency to sickness on sitting up. At the end of a week there was a sudden and violent aggravation * Ollivier ut supra. f M. Gaultier de Claubry, Jour. Gen. de Med. 1808. 376 SPINAL APOPLEXY. of this pain, followed by general convulsions, which were fatal in five or six hours. The spinal canal was found filled with extravasated blood, in the lumbar region, which had been the seat of the pain. The brain and all the other vis- cera were sound.* 4. A miller, in lifting a heavy sack, suddenly lost the use of his lower extremities, and died in fifteen days. Ex- travasated blood was found, mixed with sanious matter, in the spinal canal. The membranes were inflamed, and the nerves of the c^uda equina appeared rotten, as if they had been long macerated in putrid water.t 6. A gentleman died of a disease which was considered as apoplectic, but in which ho retained his mental faculties to the last. No disease was discovered in the brain, but there was a great quantity of extravasated blood in the spinal canal. J 6. A man received a violent blow on the three inferior lumbar vertebrae, by a log of wood which fell upon him; he died in four hours. Extravasated blood was found in the spinal canal, but the vertebrsa were entire, and the cord was healthy. § 7. A boy, aged 14, received a violent jerk of his neck by a cord which was thrown over his head as he was swing- ing forward in a swing. He felt no bad effect at the time, but, after some time, became inactive and weak in the limbs, with stiffness of the neck, and difficulty in moving his head. Nine months after the accident the weakness of his limbs increased to paraplegia; and soon after he had paralysis of the arms, with retention of urine. He had * Chevalier Med. Chir. Trans, vol. iii. f Chevalier, ut supra. % Du Hamel, Reg. Scient. Acad. Histor. An. 1683. Sec. 5, cap. 2. p. )4. • § Morgagni, Epis. 54. FUNGUS OF THE COKD. 377 been a short time in this state when he was seized with violent pain in the spine; he then had difficult and quick breathing, which was first observed during sleep, but af- terwards continued while he was awake; and he died after suffering severely from it for two days. His death hap- pened about ten months from the injury, and a few days after the violent attack of pain in the spine. A large quantity of extravasated blood was found in the spinal ca- nal, betwixt the bone and the theca vertebral is. It was partly coagulated, and partly fluid, and appeared to have come from the upper part of the canal about the second or third cervical vertebra.* SECTION V. THICKENING AND FUNGOID DISEASE OF THE MEMBRANES OF THE CORD, AND FUNGUS OF THE CORD ITSELF. 1. The Count de Lordat, aged 35, received an injury of the neck by being overturned in his coach from a high and steep bank. He felt at the time only some pain in his neck, which went off in a few days. Six months after, he had weakness of the left arm, and some difficulty of ar- ticulation, and these symptoms continued stationary for nearly twelve months. They then increased, the arm be- coming withered and useless, and his speech nearly lost, and he had involuntary convulsive motions of the whole body. After another long interval, his right arm became benumbed; he was also seized with dyspnoea and difficulty of swallowing, and his body was much emaciated. His bowels were loose; his urinary functions were natural. * Howship's Obscrv. in Surgery and Morbid Anatomy, p. 378 FtJNGUS OF THE CORD. His death happened suddenly, nearly four years after the accident. His intellectual faculties had remained entire, his lower extremities had been for a considerable time weak and unsteady, but not entirely paralytic; for he could walk from one room to another, leaning on a man's arm, a few hours before his death. The spinal cord included in the cervical vertebras was found remarkably firm, and the membranes of this portion were so dense, that there was great difficulty in cutting through them. The medulla ob- longata appeared one-third larger than natural. The pia mater was thickened, and, towards the falx, there was some appearance of suppuration; the ventricles were full of wa- ter. The lingual and brachial nerves, at their origin, were very compact or nearly tendinous. This hardness was found, in the cervical nerves, to be owing to the density of the membrane covering them.* 2. A young man, aged 14, fell from a window in the second story of a house into the street. His back was much bruised, but without fracture; and he afterwards con- tinued to walk with his body bent considerably forwards. After three years and a half, he was seized with violent pain in the back, thighs and legs; and a tumour began to form over the lumbar vertebrae, which increased gradually till it attained to a very great size. The prominent part of it was red, and repeated attacks of haemorrhage took place from the apex of the tumour. He was then affected with complete paraplegia, incontinence of urine and feces, and extreme emaciation; and at length died gradually exhaust- ed, about six years after the accident. On dissection, the tumour was found to consist of a large fungous mass re- sembling the medullary substance of the brain, which took its origin from the spinal cord, and had extended itself up- wards and downwards, from the third dorsal vertebra to ■ * London Medical Observations and Inquiries, vol. iii. FUNGUS OF THE CORD. 379 the coccyx. Many of the vertebra?, both dorsal and lum- bar, were extensively carious on the posterior part, and some of the lumbar vertebrae had nearly disappeared. There was a general softening of all the bones of the spine and of the sacrum and ilium.* 3. A man, aged 20, in the beginning of 1815, had first im- paired digestion, then difficult breathing and palpitation; and, in the end of April, he had anasarca of the legs, and such strong and extended pulsation of the heart, as left no doubt of the existence of dilatation and hypertrophia of the left cavi- ties of the heart. He was relieved by diuretics, and continued better till May, when he had pain, tenderness and distention of the abdomen. After free evacuation of the bowels, these symptoms subsided, and, about the 18th May, it was first ob- served that he had weakness of the lower extremities, with- out diminution of sensibility. All the other symptoms now disappeared. On the 20th of May, the paraplegia was com- plete, with retention of urine; and he now, for the first time, complained of pain in the loins. There was still no diminu- tion of sensibility, but, on the contrary, the limbs, when moved, were extremely painful. His digestion was now good, his breathing easy, the action of the heart natural, and his mind entire; and he continued in this state till the 22d of July, when the paralytic limbs became insensible. Gangrene then'took place on the sacrum, and he died on the 10th of inspection.—The bodies of the third, fourth, and fifth cer- vical vertebra were unequal and slightly softened, and the anterior ligament was destroyed. The outer membrane of the cord at this place had degenerated into a thick fungous tubercular mass, of the firmness of the pulmonary tubercles not suppurated, and of a greenish-yellow colour. This mass extended one decimetre and five millimetres in length and four millimetres in breadth, and involved in it the ganglions * New London Med. Journal for 1792. 380 INDURATION OF THE SHNAL CORD. of the seventh cervical and three first dorsal nerves. The portion of the cord covered by this mass was in a state of ra- mollissement, which affected chiefly the anterior columns; but the posterior columns were also slightly softened, in a space corresponding to the three upper dorsal vertebrae. The brain was sound, except a small tubercle in the right hemis- phere; the heart was quite sound, and the lungs, except one small tubercle, not softened. In the abdomen there were adhesions and some puriform fluid.* Fungoid disease of the dura mater of the cord is also met with in connexion with disease of the vertebrae; several cases of this kind are related by Ollivier. SECTION VI. INDURATION OF THE SPINAL CORD. This part of the pathology of the cord is exemplified in the remarkable case of the Marquis de Causan. His com- plaint began with a prickling in the fingers and toes of the right side, which extended gradually upwards along the arm and leg: the parts wasted, became cold, and lost their feeling; but they retained such a degree of motion, that he could walk with the assistance of a crutch under the arm of the affected side. He had continued in this state more than a year, when the left side became affected in the same manner. He was then confined to bed, and incapable of any motion, either of the trunk or extremities, the other functions continuing for some time in a healthy state. His sight and hearing were next affected, being first weakened, and gradually destroyed. In * Serres, Anat. Comp. de Cervcau, torn. ii. p. 234. compression of the spinal cord. 381 the same gradual manner, he lost his speech and the power of swallowing; and soon after this he died. The pulse and breathing had continued natural until a short time before death, when both became remarkably slow; the pulse being from 30 to 40 in a minute. On dissection, the brain and all the viscera were found in the most healthy state. That part of the spinal cord which is included in the cervical vertebrae was so hard as to have the consistence of cartilage; and the membranes of this portion were red as if inflamed.* SECTION VII. NEW FORMATIONS COMPRESSING THE SPINAL CORD. These occur under the same variety of forms which have been already referred to in regard to the brain. The most common appear to be the fleshy and albuminous for- mations, tubercles, hydatids, and ossifications. 1. A woman, aged 36, had first some convulsive mo- tions, which soon ceased; then acute pain of the left arm with headach: the arm became weak, and gradually com- pletely paralytic. She then had convulsive motions of the lower extremities, which also became completely paraly- tic The right arm next became painful, and the motion of'it was impaired, but not entirely lost. The inferior extremities became edematous; the inferior half of the thorax, and all the parts below, were completely deprived of sense and motion: and the right arm at last also became entirely paralytic. Extensive gangrene then took place on the sacrum, and she died gradually exhausted somewhat * Portal, Com* d'Anatomie Medicale, torn. 49 382 COMPRESSION OF THE SPINAL CORD. more than three months from the commencement of the paralysis. Inspection.—On the anterior part of the cord, betwixt the body of the cord and the arachnoid, there was a tu- mour of a reddish-yellow colour; it was about three lines in thickness at the thickest part, and covered the anterior surface of the cord, from the sixth cervical nerves to the third dorsal: and the part of the cord which was covered by it was considerably flattened. Internally, the tumour was of a firm fleshy consistence, and of a yellowish-white colour. On many parts of the arachnoid of the cord, car- tilaginous scales were observed.* 2. A young man, aged 14, received a blow upon the spine between the shoulders, by falling backwards against the corner of a chair. The only effects which immediately followed the injury, were, that he was observed to hold his chin down towards the breast, and that he complained, on raising his head, of a pain striking through and across his chest. After four weeks, he was affected with weak- ness of his legs, which increased till, in a short time, they became entirely paralytic. About the same time, he lost the power of retaining his urine and feces. He had con- tinued in this state for two or three weeks, when his arms became paralytic, and he then lost the power of moving his head. He died on the following day, about three months after receiving the injury, having continued sen- sible to the last. During the progress of the disease, he frequently complained of great oppression and pain darting through the chest. On dissection, the viscera of the tho- rax and abdomen were found to be healthy. Some bloody serum escaped in opening the head, but the brain in other respects was sound. Much bloody serum was discharged from the spinal canal, and, on opening it, a soft substance * Velpcau, Arch. General, de Med. January, 1825. COMPRESSION OF THE SPINAL CORD. 383 was found, four inches in length, lying betwixt the bones and the spinal cord at the place of the injury. When this substance was taken out, and shaken in water, a great part of it was dissolved. Parts of the same substance had pro- truded through between the transverse processes of the fourth and fifth dorsal vertebrae, and formed two tumours of similar soft matter, lying one on each side of the spine, in the hollow betwixt the spinous and transverse pro- cesses. The largest of these was between three and four inches long, one and a half broad, and about an inch in thickness. The spinal cord and the vertebrae were sound.* 3. Tubercles are found of various sizes, either in the substance of the cord or attached to its membranes, and they present the same characters as the tubercles of the brain. The symptoms vary exceedingly, according to the seat and size of the tubercles, or as they happen to affect particular nerves. A child, aged 12, mentioned by Ollivier, had been long subject to convulsive attacks, which occurred at irregular intervals, and affected chiefly the arms: he died of phthysis. A tubercle, the size of a nut, was found be- twixt the dura mater and the arachnoid of the cord at the third cervical vertebra. In a case by Bayle, there was to- nic inflection of the fore-arm, hand, and fingers; and in one by M. Gendrin, there were epileptic paroxysms, which al- ways commenced with a violent attack of hiccup, of one or two minutes' duration. There were two large tubercles in the substance of the cord at its very origin. In a case of paraplegia, mentioned in Majendie's Journal, two small tu- mours were found attached to the cord at its lower extre- mity Harderus found a tumour the size of a nutmeg, com- pressing the spinal cord of a young woman; and there were three similar tumours in the cerebellum. From his description, they were evidently tubercles, and the case • London Med. Obs. and Inq. vol. iii. 384 COMPRESSION OF TnE SPINAL CORD. was complicated with disease of the lungs and the liver. The leading symptoms were, severe headach, oppressed breathing, and, a few days before death, violent convul- sions. 4. Hydatids in the spinal canal have been mentioned by various writers. A woman mentioned by Esquirol be- came epileptic after a fright, and the fits returned every se- cond or third day with great violence for three years. She then became comatose after one of the paroxysms, and died in five days. The pituitary gland contained a cyst full of a reddish-brown fluid, and hydatids of various sizes were found within the sheath of the spinal cord through its whole extent. In a case of paraplegia of nine months' standing, M. Chaussier found a mass of hydatids attached to the spine behind the left kidney, and a branch from the mass entered betwixt the vertebra; into the spinal canal. A similar case is related by M. Reydellet in the Diet, des Sc. Med., in which the tumour was opened, and the spinal cord was found exposed at the bottom of it, after a large quantity of hydatids had been discharged. The patient re- mained paraplegic. 5. Ossification of the membranes of the cord has been observed in several cases. In a woman who had been epi- leptic for five years, and died suddenly in one of the fits, Esquirol found the sheath of the spinal cord, on its exter- nal surface, covered through its whole extent with osseous scales, from one to two lines in diameter. In a case de- scribed by M. Barbier,* the affection began with prickling and numbness of the legs, which extended very gradually, and was afterwards accompanied by acute pain in the limbs, and after several months terminated in complete paraplegia, with incontinence of urine. The patient, a woman of 55, continued in this state about three years. She was then * Traite Element de Mat. de Med. DESTRUCTION OF THE SPINAL CORD. 385 seized with acute pain in the back, extending into the sto- mach and abdomen, and down the legs, and accompanied by vomiting, fever, delirium, and convulsive motions of the limbs. She died after a short illness, the duration of which is not distinctly stated, but seems to have been eight or ten days. At the third dorsal vertebra, there was an ossification of the membranes of the cord half a line in thickness, three lines broad, and two inches long. The inner surface of this production was concave and covered with a soft membrane; and the portion of the cord in- cluded in it was almost destroyed, the membrane contain- ing only a small quantity of viscid fluid. Above this, the cord was firm and healthy; below, it was much wasted. 6. The cord may also be compressed by a diminution of the spinal canal, but this appears to be a very rare occur- rence. It was, however, observed by Portal. The canal of the last dorsal and two upper lumbar vertebrae was di- minished one half, and its inner surface was rendered une- qual by numerous small bony eminences. The inferior ex- tremities were much wasted. SECTION VIII. DESTRUCTION OF A PORTION OF THE SPINAL CORD. A man, whose case is related by Mr. Copeland, had pa- raplegia, dysuria, obstinacy of the bowels, and a feeling of tightness across his belly, as if a broad band had been bound tightly round it. His health had been declining for more than a year, and the commencement of his complaints was ascribed to having violently sprained his back in lifting a heavy weight. After being confined to bed with perfect paraplegia for three months, he died of gangrene of the nates. On dissection, no disease could be discovered in 386 concussion of the spinal cord. the vertebrae. Within the last dorsal and first lumbar ver- tebrae, the spinal cord was entirely wanting for more than two inches. The membranes, which there formed an empty bag, were unusually vascular and much thickened.* On the other hand, Ollivier found four inches of the cord entirely wanting in a child, aged 8 years, who died of ex- treme marasmus, with caries of the vertebrae, but without loss either of sensibility or motion of the limbs. Velpeau has described several cases, in which, in connexion with caries of the vertebrae, the cord was completely destroyed for the space of several inches, the patient having died of gradual marasmus without any appearance of paralysis; and in Majendie's Journal, a case is described, in which the cord had become quite liquid, through two-thirds of the dorsal region, and one-third of the cervical. The arms were paralytic without loss of sensibility, but the legs were not affected. Ollivier has also observed in two cases a remarkable wasting or diminution of size of the cord. The one was in an old man, without any particular symp- toms; the other in an idiot, with permanent contraction and wasting of the limHs. SECTION IX. CONCUSSION OF THE SPINAL CORD. ' A severe blow upon the spine frequently occasions an immediate loss of power of the parts below the seat of the injury, without producing either fracture or dislocation of the vertebrse. The extent of the parts affected will, of course, depend upon the seat of the injury. Paraplegia * Copeland on Diseases of the Spine. CONCUSSION OF THE SPINAL CORD. 387 and retention of urine are the symptoms which most com- monly come under our observation; but, if the injury be on the upper part of the spine, there may also be paralysis of the upper extremities, difficulty of breathing, and af- fections of the voice. In tracing the farther history of this affection, the following circumstances are worthy of attention. ----J 1. Concussion of the cord may be speedily fatal without producing any morbid appearance that can be detected on dissection. Many cases of this kind are on record. Boyer mentions a man who received an injury of the spine by falling into a ditch. He was immediately affected with complete paraplegia, and died in consequence of the inju- ry; the period of his death is not mentioned. On dissec- tion, no disease could be discovered either in the head or the spinal canal. Frank mentions four fatal cases of con- cussion of the spine, in none of which could any morbid appearance be detected, either in the vertebrae or in the spinal cord. 2. It may be fatal by inflammatory action taking place in the cord or its membranes, and terminating by ramollisse- ment, suppuration, or effusion. Case CXXXIX. affords an example of this affection fatal by ramollissement. A re- markable case, fatal by extensive suppuration, has been al- ready quoted from Mr. Charles Bell. Boyer mentions a man who fell from a height of fourteen feet, and remained for some time senseless. On recovering from that condi- tion he was found to have lost the use of his lower extre- mities. He had also retention of urine and involuntary discharge of feces, and died in twelve days. On dissection, a quantity of bloody serum was found in the spinal canal, the quantity of which was sufficient to fill a little more than the lower half of it. 3. Urgent symptoms may follow the injury, and after some time may be removed. Galen mentions a man who, after an injury of the back, was affected With loss of speech, 388 CONCUSSION OF THE SPINAL CORD. loss of voice, and paralysis of the lower extremities, the superior extremities remaining unaffected. After seven days he recovered his voice and speech, and soon after the palsy also disappeared. In summer, 1816, I saw a man who had been employed in blowing a rock near Edinburgh. Not having retired to a sufficient distance, and standing with his back to the rock when the explosion took place, a large piece of stone struck him on the spine about the lower dorsal and upper lumbar vertebrae. He instantly fell, completely deprived of power in the lower extremities. I found him in this state a few hours after the accident, when he also complained of vio- lent pain, beginning in the seat of the injury, and extend- ing downwards along the thighs. On the back there was an extensive swelling, which made it impossible to ascer- tain the state of the vertebrae. He was confined to bed for several weeks without any power of his lower extremities, and with considerable difficulty in passing his urine, but gradually recovered, and in a few weeks more was free from complaint. The practice vyhich was employed, con- sisted chiefly of general and topical blood-letting. In Hufeland's Journal, vol. xxi. is related the case of a man who fell from the top of a cart-load of wood, and lighted so that the weight of his body, on first coming to the ground, rested upon the back of his neck and shoul- ders, his head being bent forwards. When he recovered from the first effects of the shock, it was found that he had lost completely both feeling and motion of all the parts be- low the neck; he could movo no part but his head, and he had retention of urine and obstruction of the bowels. Af- ter eight or ten days, he was affected with anasarca of the limbs, and a sense of prickling followed by severe pain, but without any power of motion. After lying several weeks in this state of perfect paralysis, he began to recover a slight degree of feeling and motion, beginning in the fingers; and from this time, the power of motion increased CONCUSSION ON THE SPINAL CORD. 389 very gradually, so that at the end of sixteen weeks he was able to support himself in a sitting posture on a chair. After another long interval, he was able to drag himself about, supported upon crutches: and, at the time when the case was written, he was able to walk a little supported by a stick, and to do a little work with his hands, but he con- tinued to have great weakness and pain of his back, the * pain being chiefly referred to the junction of the spine with the sacrum. The progress of the functions of the bladder and the bowels, in this case, is somewhat remarkable. He had first complete retention of urine, requiring the use of the catheter for four weeks; he then recovered the power of passing his urine, but could not retain it; it flowed in- voluntarily, and after some time longer, he recovered the power of retention. The bowels were not moved without strong glisters for six weeks; after this the stools passed involuntarily for four weeks, and he then recovered the natural action. A man, mentioned in the Journal Universal, torn, xxviii., fell from a tree and lighted on his back, and likewise struck the back of his head, in which a wound in the integuments took place. He was for some minutes thrown into a state of syncope, on his recovery from which it was found that the lower extremities were entirely deprived of sense and motion. He had afterwards retention of urine, tumefac- tion of the abdomen, headach, dilatation of the pupil, ex- treme anxiety, difficult deglutition, and stertorous breath- ing, and the pulse was as slow as 38 in a minute. He re- covered gradually, and was well in three weeks. Some cases of injuries of the spine have been accompa- nied by loss of motion without loss of feeling, and others by loss of feeling without loss of motion. In a singular case described by Ollivier, there was incontinence of urine, with loss of feeling of the penis and scrotum, and of the anterior, posterior, and interior part of the thighs without any loss of motion. In such cases the sensibility of the 50 390 CONCUSSION OF THE SPINAL CORD. parts sometimes returns gradually, and in others the affec- tion is permanent. 4. It may produce permanent paralysis. This may oc- cur immediately, or the first effects of the injury may be recovered from, and a new diseased action may take place after a considerable time. Several examples of this have already occurred under the foregoing heads. The slight nature of the first symptoms, in such cases, and the slow- ness of their progress, will be illustrated by the following case. Case CXLIV.—A man, aged 54, about twenty years ago, fell from the branch of a tree, and lighted on the sa- crum. He was carried home, complaining of pain in the lower part of the spine, and entirely paralytic in his lower extremities. In this state he was confined to bed about twelve days, and then recovered, so as to be able to follow his usual employment; but from this time he was affected with a peculiar feeling of numbness, which was confined to the upper part of the left foot. This feeling gave him no inconvenience, but never left him. After he had con- tinued in this state for four years, the numbness suddenly extended upwards along the leg and thigh, and was speedi- ly followed by paralysis of these parts. After some time he was seized with pain, which stretched across the lower part of the back, and into the right thigh, and was soon followed by paralysis of the right thigh and leg. He was then confined to bed with perfect paraplegia for about two years. Some time after this he recovered so much power as to drag himself about supported upon two crutches. He was in this state without any farther improvement, when I saw him for the first time, upwards of eleven years ago. His spine was free from distortion, but he complained of deep-seated pain upon pressure about the last dorsal vertebra, and at the top of the sacrum. Two caustic is- sues were inserted, and under the action of them he made CONCUSSION OF THE SPINAL CORD. 891 some improvement; he was able to raise his legs a little higher in walking, and occasionally to stand without his crutches, but since that time he has continued stationary, and is much distressed with incontinence of urine. The morbid action which takes place in such a case as this, will be illustrated by the facts which have been al- ready recorded. It is probably of the nature of chronic inflammation of the cord or its membranes, terminating by some of the morbid conditions which have already been referred to. We have seen that such affections may super- vene upon very slight injuries of the spine, which do not at the time of receiving them induce any urgent symptoms, and perhaps attract little or no attention. Sometimes they take place after so long an interval that the patient has for- gotten the injury, or if he remembers it, does not consider it as having any connexion with his disease. A man men- tioned by Mr. Charles Bell, became paralytic in the lower extremities, several months after a slight injury of the spine, occasioned by striking his back against the corner of a table. A gentleman walking in the fields near Edin- burgh sprained his back slightly in leaping over a wall. He felt little uneasiness at the time, but, after several weeks, his lower extremities became paralytic. In this state he continued four or five months, and then gradually recovered under the usual treatment. In other cases the symptoms take place at an early period, and with such activity as distinctly marks inflammatory action. A young man mentioned by Dr. Jebb received a blow on the spine from a stone. In the evening of the same day he was seized with shivering, followed by fever, which ran high through the night, but abated in the morning. He had at the same time pain in the stomach and back, with contrac- tion of the legs; and this was followed by weakness of the lees, which, after ten days, increased to perfect paraplegia. Issues were then inserted, and he was able to walk in three months. 392 CONCUSSION OF THE SPINAL CORD. Every injury of the spine should be considered as de- serving minute attention, and the most active means should be employed for preventing or removing the diseased ac- tions which may result from it. The more immediate ob- ject of anxiety in such cases is inflammatory action, which may be of an active or of a chronic kind; and we have seen that it may advance in a very insidious manner, even after injuries which were of so slight a kind that they at- tracted at the time little or no attention. When the inju- ry is of a more violent nature, there is indeed another ob- ject of attention, that is, fracture or dislocation of the ver- tebrae. But we have seen that the most urgent symptoms may take place immediately after the injury, and may even be speedily fatal without any affection of the vertebrae; while, on the other hand, it is often impossible to ascertain the state of the vertebrae, in consequence of the external swelling which takes place. It is likewise to be kept in mind, that fracture of the vertebrae may happen without any displacement of parts, and in such a situation, that it is impossible to discover it. A case is mentioned by Cam- per, in which paraplegia took place after an injury of the spine, and which gradually recovered after twelve months. On the death of the patient, which happened some time af- ter from fever, he found that one of the lumbar vertebrae had been fractured in the body without displacement, and had united. Under this head, I may allude very briefly to the subject of wounds in the spinal cord, in regard to which there are some very singular facts upon record. A young man, mentioned by Ollivier, was struck with a poniard through the upper part of the neck, and fell instantly, deprived of feeling and motion of all the parts below the head. He had also reten- tion of urine, but recovered gradually, and was able to walk a little in about five months. In a similar case by Boyer, the man recovered, but with palsy of the right arm, and loss of AFFECTIONS OF THE BONES OF THE SPINE. 393 feeling of the left side in all the parts below the thorax. The case is well known of a man, mentioned by Dessault, who lived twenty-four hours, and moved all his limbs freely after the cord had been completely divided by a musket bullet at the tenth dorsal vertebra. A still more remarkable case is re- lated in the Memoirs of the Academy of Sciences. A man received a wound with a sword among the lower dorsal ver- tebrae, which soon healed, and he was afterwards able for long marches. After a considerable time, the place became painful, suppurated, and was opened; and a piece of the point of the sword, two inches long, was extracted. He died in thirty-six hours; and it was found that the sword had pene- trated betwixt the spinous and oblique processes on the left side, that it had completely traversed the spinal canal, and had lodged in the opposite side. A man mentioned in the first volume of the Archives Generales de Medecine, received a wound by a musket bullet, which entered at the groin, and came out near the first lumbar vertebra. The wound soon healed, but after a short time loss of feeling began around the cica- trix, and gradually extended until it affected the whole left side of the body except the face. Any part of the thorax, the abdomen, or the leg or arm of that side, could be pinched with any degree of force without feeling. The power of mo- tion was preserved, though it seemed weaker than in the other side. His health was otherwise unimpaired. After the affection had continued in this state for years, it was re- moved under the use of a succession of large blisters. SECTION X. OF CERTAIN AFFECTIONS OF THE BONES OF THE SPINE. It would be foreign to my purpose to enter minutely upon this important subject; but there are some circumstances re- 394 AFFECTIONS OF THE BONES OF THE SPINE. lating to it, which it may be proper to mention very briefly, in connexion with the object of this essay. In the ordinary cases of carious and distorted vertebrae, accompanied by paraplegia, it is well known that the paralysis is not produced simply by the distortion; for the distortion may exist in a very great degree without paralysis; and, when they have existed together, the paralysis may be entirely re- moved, while the distortion remains undiminished. It appears that it is the inflammatory action of the parts which deranges the function of the cord; that the effects of this in reference to the cord may subside, though the disease of the bones may go on to anchylosis and permanent distortion; or that, on the contrary, it may terminate by fungoid disease of the mem- branes, or chronic disease of the cord itself, and thus the palsy become irremediable. The original disease appears to be in some cases seated in the ligaments and membranes; in others, in the articulating surfaces and intervertebral car- tilages; and in others, in the bodies of the vertebrae. It is when the bodies of the vertebrae are extensively affected, that the caries which follows produces distortion; but, even in this case, distortion is not an invariable consequence, for the caries may take place in such a manner as to diminish the size of the vertebra equally along its whole surface, and thus merely to shorten the spine without distorting it. This is said to oc- cur most frequently in the lumbar vertebrae. The case of a boy, related by Dr. Armstrong, is very important. He had involuntary discharge of urine and feces, difficult breathing, and paralysis of all the extremities except a very imperfect degree of motion of the left arm. There was much pain and ten- derness on pressure in the cervical vertebrae, but no distortion. He recovered completely in a few months, the vertebrae that had been affected remaining in a state of anchylosis. In this case, the disease was probably confined to the articulating surfaces. Mr. Copeland gives a plate, in which three of the dorsal vertebrae are represented as united by anchylosis, the intervertebral cartilages being removed, but without any loss AFFECTIONS OF THE BONES OF THE SPINE. 395 of substance in the bodies of the vertebrae. In this case, pa- ralysis had taken place, but there was no perceptible distor- tion. In attending to such cases in practice, therefore, it is not sufficient to ascertain the existence or non-existence of distortion. The whole spine should be examined with care, with the view of detecting the existence of inflammatory ac- tion. This will be indicated by pain or tenderness on pres- sure, or pain on passing a hot sponge over the part in the manner recommended by Mr. Copeland. The disease in its early stages is sometimes of very small extent: in a case which occurred to me some time ago, it was limited to a spot on one side of the spine, which could almost be covered by the point of the finger; but it was of so peculiar a nature, that very moderate pressure upon the spot produced syncope. The patient was an officer in the navy, and got well under the nsiifil treatment* A minute examination of the spine, therefore, should always be made with the utmost care, when any of those symptoms occur which have been observed to be connected with af- fections of the spine or spinal cord, especially if they do not yield readily to common modes of treatment, or if they have occurred after injuries of the spine. The principal symptoms of this kind are the following -.^-Weakness, numbness, or con- vulsive affections of any of the limbs; spasmodic Parting of the limbs, occurring chiefly during the night; loss of the full power of the muscles, so that though the patient can walk with sufficient steadiness, he cannot perform such motions as are required in running or leaping; numbness a bug the margin of the ribs, and a peculiar oppression and tigh ness across the region of the stomach; various affections of he breathing; difficulty in discharging the urine and feces, or difti- cu ty in r taining them. Complaints such as these have some- times been found to be connected with affections of the spine or spinal cord, after they had been mistaken for dyspeptic or asthmatic disorders, or for diseases of the urethra or rectum A ca- has been formerly described in which an affection of 396 AFFECTIONS OF THE BONES OF THE SPINE. the spinal cord, at one period of its progress, was accom- panied by all the symptoms of hypertrophia of the left side of the heart; but these disappeared long before death, and the heart was found on inspection perfectly healthy. It is indeed true, that diseases of a most formidable na- ture may exist in the cord itself or its membranes, though nothing can be detected by the most careful examination of the spine; but these are quite distinct from the particular class of affections which are here referred to, and in regard to which we cannot be too attentive in watching the very earliest indications. One symptom, in particular, which should always be contemplated with much suspicion, is a feeling of tightness or constriction along the margin of the ribs, as if a tight band were passed across the stomach. This is generally accompanied with a feeling of distention in the lower part of the abdomen, as if the bowels had in part lost the power of propelling their contents. These feelings may be considered as merely flatulent or dyspep- tic, and in many cases, they may in fact be nothing more; but they will likewise be foun'd by an attentive observer, to be frequently among the first indications of a dangerous affection of the spine, and to exist before there is any af- fection of the limbs, or any disease can be discovered in the spine itself. In one of the last cases that occurred to me, symptoms of this kind had existed for nearly three months before a projection was discovered in one of the lower dorsal vertebrae, and this was soon followed by per- fect paraplegia. It is worthy of attention, that symptoms affecting inter- nal organs may exist in connexion with diseases of the spine, without being attended by any affection of the limbs, or any symptom calculated to direct our attention to the spine as the seat of the disease. A girl mentioned by Mr. Copeland, had difficulty and pain in emptying the bladder, pain and tightness round the margin of the tho- rax, and difficult breathing; her limbs were not affected, AFFECTIONS OF THE BONES OF THE SPINE. 397 except that she was more easily fatigued than her compa- nions. One of the dorsal vertebrae was found to project a little, and by topical bleeding and blistering on this part, and rest in the horizontal posture, all her complaints were removed. A man mentioned by Dr. Jebb, had pain under the short ribs on both sides, cough and irregular pulse. From the parts affected, lancinating pains extended down- wards along the thighs, occasioning much uneasiness in walking, resembling the pains of rheumatism. The ninth or tenth dorsal vertebras was found to protrude, and by is- sues applied at that place, all his complaints were removed. The remedies on which we chiefly rely in all cases of this kind are topical bleeding, blistering, issues and rest in» the horizontal posture; but some cases are on record, show- ing in certain conditions of the disease the beneficial effects of mercury. A girl mentioned by Mr. Charles Bell, after an injury of the spine, was confined to bed for eight months in the most helpless state, her back bent, and her knees drawn up. She recovered entirely under a course of mer- cury, given her on account of syphilis, with which it was discovered that she had been affected from the time of the accident. In the transactions of a Society for the Im- provement of Medical and Surgical Knowledge, is related the case of a man, who had squinting, difficulty of swal- lowing, indistinct articulation, paralysis of the left leg and arm, and protrusion of several of the cervical vertebrae. Under a course of mercury all his complaints disappeared, and the protrusion of the vertebrae was diminished, though not entirely removed. Several cases have recovered by confinement to the horizontal posture without any other remedy; this occurred in Dr. Armstrong's case lately re- ferred to. The spine may be affected with extensive caries without the existence of any symptom that marks such a state of disease. A man mentioned by Mr. Charles Bell, who had 51 398 AFFECTIONS OF THE BONES OF THE SPINE. been liable to severe pain in his back, and fits of palpitation, died suddenly after a long walk. The only morbid ap- pearance observed on inspection was a large scrofulous ab- scess in the posterior mediastinum, with caries of several of the vertebrae, of such extent that the spinal cord was exposed in several places. I saw a similar abscess in the posterior mediastinum, with caries of the bodies of five or six of the vertebrae, in a girl who died of phthisis. She had complained for some time of severe pain in the back, but her complaints in other respects did not differ from the usual symptoms of phthisis. A similar appearance in the lumbar vertebrae, with a psoas abscess containing two •pounds of matter, has been described by Mr. Benjamin Bell.* The vertebrae were so diseased, that large pieces of them were separated, and the matter was in several places in contact with the spinal cord. The patient, a man of 40, had complained of severe pain in his back and thighs, which prevented him from raising his body into the erect posture, but there was no distortion of the spine, and no paralysis. He had considerable difficulty of breath- ing, but this was accounted for by a diseased state of the lungs. Other remarkable cases are on record, showing ex- tensive disease of the spine without any fatal results. Du- verney found the atlas so brought forward upon the fora- men magnum, that there was not a space of more than two lines in diameter left for the cord; and Bertin has de- scribed a preparation, in which the atlas was so anchylosed with the occipital bone, that its posterior arch crossed the centre of the foramen magnum. The history of this case is not given, but it is evident, from the anchylosis, that it was not speedily fatal. Similar contractions have occurred, though not to the same extent, in the ordinary cases of ca- ries of the spine, terminating by distortion and anchylosis, but without paralysis. • Edin. Med. Cora. vol. iiL AFFECTIONS OF THE BONES OF THE SPINE. 399 In connexion with this subject, it may be right to allude very briefly to some of the phenomena connected with the affections of the processus dentatus. 1. It may be affected with caries without producing any urgent symptoms, until it suddenly give way and prove fatal. A man, mentioned by Mr. Copeland, had been using mercury for a disease in the tibia, and had for some time complained of stiffness and pain when he moved his head. On making a sudden turn of his head he was seized with convulsions, and died in a few hours. On inspection, the processus dentatus was found completely detatched from the vertebra, having been eroded by caries. A woman mentioned by Ollivier, had pain in the neck and difficult deglutition; the muscles of the neck were rigid, and the least motion of the head was insupportable, so that she was constantly confined to the horizontal posture, and almost to one particular position; she then had cough and difficult breathing, and at last died after several months. There was extensive disease of the lungs, and the processus den- tatus was entirely destroyed by caries. The posture in which this woman had been long confined probably pre- vented her more sudden death. 2. It may be dislocated by violence, of which many exam- ples are on record. A man mentioned by Mr. Charles Bell, was making a violent effort to propel a wheelbarrow from the street upon the raised foot pavement, when the wheelbarrow suddenly went from before him, and he fell with his chin upon the curb stone. He was dead in a few seconds; the pro- cessus dentatus was found to have crushed the spinal cord, the ligaments having given way. 3 It appears that the ligaments of the processus dentatus may yield in a more gradual manner, giving rise to a course of argent symptoms for some time before the affection is fatal Some years ago, a man was received into the Infirmary of Edinburgh, who had been accustomed to carry burdens on his left shoulder, his head consequently being bent to the right 400 AFFECTIONS OF THE BONES OF THE SriNE. side. He complained of pain in the forehead and occiput, extending down the neck, pain in the throat, great difficulty, or rather impossibility of swallowing, articles taken into the oesophagus being rejected with some violence after they had passed a short way. He had rigid contractions of the neck and back, resembling tetanus; his articulation was slow and difficult, and the pulse 54. These complaints had begun about six weeks before, and had been increasing gradually; difficulty of swallowing was one of the first symptoms. Two days after his admission, his left side became paralytic; on the following day, the right was affected in the same manner, and his breathing became laborious. He died in three days more, having lost all power of moving the parts below the neck. On inspection, it was found that the ligaments had given way on the left side of the processus dentatus, so as to allow it to compress the spinal cord. No other disease could be disco- vered in any of the viscera. For the following important case I am indebted to Dr. Hun- ter. It illustrates in a striking manner many of the observa- tions made in this section, and shows, in connexion with the disease of the vertebrae, complete paralysis, without any re- markable affection of the body of the cord. Case CXLV.—A young lady, aged 15, in the beginning of the year 1825, began to complain of a dull pain in the neck, which, to a certain extent, limited its motions. She became languid, depressed, and sallow; and the symptoms went on in this manner, without exciting much attention, till about the middle of March. Dr. Hunter was then consulted about her, on account of an increase of the uneasiness in her neck, which was accompanied by considerable swelling in the back part of it. Several tumours had also appeared on the scalp, in which fluctuation was felt, and on opening them, the bone be- neath was found to be carious. The swelling of the neck gradually increased to a great extent on each side of the spine, and became irregularly softened; and when opened, discharged AFFECTIONS OF THE BONES OF THE SPINE. 401 ill-conditioned strumous matter, in small quantities. The pain in the neck increased to such an agonizing degree as to- tally to prevent motion; it extended at times to the left side of the head and face, and fixed, for a certain time every day, with excruciating severity, over the left eye. At an early period of her illness, numbness of the superior extremities took place, which increased to perfect paralysis; there was also rigid contraction of the flexor muscles of the legs, with a slight degree of twisting of the mouth. The pulse became frequent; the breathing was natural when she was awake, but during sleep was accompanied by a loud snorting noise. The appetite was tolefable, and the other functions were natural. The caries of the bones of the skull gradually penetrated both tables, without any affection of the sensorium occurring. One or two new openings took place in the swelling on the neck, from which a discharge continued. She became gradually more and more emaciated, and died exhausted on the 1st of January, 1827. Inspection.—An incision being made on the back of the neck, and carried down to the spine, gave vent to a conside- rable quantity of matter which lay in contact with the verte- brae; and the surrounding soft parts were in a state of pulpy degeneration. The four upper vertebrae were found to be more or less affected with caries, which was most remarkable in the first and second. The articulating surfaces of the at- las were deeply eroded, and there was a similar erosion of the articulating surfaces of the occipital bone. In the second vertebra, the processus dentatus was entirely separated from the body of the bone, the caries having completely penetrated it at its attachment, and there was besides considerable loss of substance on the posterior part of the vertebra. The mem- branes of the cord were thickened, and the cord itself was a little softened at the upper part, but in no remarkable de- % gT remarkable case, analogous to this, is mentioned by M. 402 AFFECTIONS OF THE BONES OF THE SPINE. Meyrieu.* The patient had pain and stiffness of the neck, his head being bent to one side, and immoveable; difficulty of swallowing; and after some months palsy of all the limbs. He died suddenly when his head was accidentally moved in do- ing some necessary office about his bed. The external parts of the neck presented a mass of soft disease. There was ca- ries of the right condyle of the occipital bone, of the right side of the atlas, and of the processus dentatus; and there was destruction of the ligaments, so that the atlas was luxated from the occipital bone. I conclude this part of the subject with the following case, which shows disease of the processus denfatus, complicated with a new formation, presenting the characters of fungus haematodes. Case CXLVI.—A gentleman, aged 22, of a scrofulous ha- bit, in the early part of his life had suffered amputation on account of a disease of the knee, and afterwards was liable to pectoral complaints with haemoptysis. In the beginning of the year 1828, he began to complain of pain and stiffness of the neck, referred chiefly to the left side of it, and much in- creased by the motion of the head. The pain sometimes ex- tended into the larynx, and backwards towards the scapu- la. After considerable relief from repeated blistering, &c. the symptoms returned, accompanied by loss of appetite, fre- quent pulse and light perspirations; and soon after this he became affected with difficult deglutition, some dyspnoea and hoarseness. There was now also severe fixed pain referred to the back of the head, and much increased by the motion of the parts; so that he was obliged to sup- port his head with both his hands when he had occasion to make any change of his posture. He was next affected with paralysis of the tongue and the upper eyelid of the left side. On 16th January, 1829, he was seized with paralysis * Bull, de la Soc. de Med. 1821. AFFECTIONS OF THE BONES OF THE SPINE. 403 of the left arm, and two days after, the right was affected in the same manner. He had then great pain and difficulty in passing urine, with obstinacy of the bowels, which nothing could overcome. On the 29th, the lower extremities became paralytic, and he died on the 31st, having suffered greatly on the day on which he died, from difficult breathing. Inspection.—All the external parts of the neck, the pha- rynx, &c. were healthy, and no disease was discovered in any of the vertebrae in their external aspect. The brain and cerebellum were healthy, except some increase of vascularity. Within the foramen magnum, and attached to the inner sur- face of the dura mater at its anterior and lateral parts, there was a spongy tumour of a grayish-yellow colour, which, when cut into, presented a variegated structure, resembling fungus haematodes. The processus dentatus was rough and carious on its surface, and it was so much elongated, as to project halt an inch into the cavity of the cranium. Its ligaments also were partially destroyed, so as evidently to allow it to encroach upon the area of the spinal canal, and to compress the cord. The spinal cord at the upper part was flattened, but not ma- terially altered in its texture. In regard to the treatment of the diseases of the spinal cord, it is not necessary to enter into any long detail, as it mus be regulated by the same principles as the correspond- ing ffectTons of the brain. In the more acute affections we Tt of course rely chiefly on free general and topical bleed- ^IZTy^l^, purgatives, and the other usual aux- Z^^ot^U succession, and repeated in this 404 PATHOLOGV OF THE SPINAL CORD. manner to a considerable number. In some of the cases great benefit is also obtained from continued moderate purging. SECTION XI. CONCLUDING OBSERVATIONS ON THE PATHOLOGY OF THE SPINAL CORD. The preceding observations on the diseases of the spinal cord, I merely propose as an imperfect plan or outline of this most important subject, in the hope that it may engage the attention of those who have opportunities for prosecuting the inquiry. When we review the phenomena which have been observed to accompany the diseases of the spinal cord, we find affections of all the principal organs of the body. In the parts connected with the head and neck, we find distor- tions of the eyes, convulsive affections of the face, difficulty and loss of speech, loss of voice, contraction of the jaw, re- sembling trismus, and difficulty of swallowing, which is said, in some cases, to have nearly resembled hydrophobia. In the viscera of the thorax, there have been'observed oppression, pal- pitation, and strong and irregular action of the heart; painful sense of stricture in the region of the diaphragm, and difficulty of breathing, which, in some cases, has been permanent, and in others, has occurred in paroxysms, resembling asthma. In the organs of the abdomen and pelvis, we find vomiting, pain of the bowels, resembling colic; tenesmus, involuntary discharge of feces, and retention or incontinence of urine. In the muscu- lar parts we observe convulsions and paralysis; the convul- sions in some cases resembling chorea, in others tetanus. Wc are by no means prepared to say, in the present state of our knowledge, that all these proceed directly from the affections of the spinal cord, especially as we observe remarkable diversities CONCLUDING OBSERVATIONS. 405 and considerable want of uniformity in the symptoms. But the subject presents to us a field of observation which promises most important and most interesting results. It has also opened up a wide field of conjecture, in regard to the influence of the spinal cord, in several diseases which have hitherto been in- volved in much obscurity. These conjectures are not to be altogether overlooked, but are of value only in as far as they direct us to subjects worthy of being investigated by farther observation. They have chiefly referred to the following points. Spasmodic Diseases.—Several writers of eminence have conceived that many spasmodic and nervous diseases have their origin in affections of the spinal cord. Hoffman, in his Essay De Morbis Discernendis, directs us to distinguish be- twixt epilepsy and convulsions. In the former he says the membranes of the brain are affected, in the latter the mem- branes of the spinal cord. In his Treatise De Morbis Con- vulsivis, he divides convulsive affections into idiopathic and symptomatic. The former, he thinks, arise from irritation ot the membranes of the spinal cord; the latter he supposes to depend upon diseases of other organs, and that the effect of them by the influence of these diseases upon the spinal cord, s extended over the whole body. Ludwig discusses the same docMnemore particularly, ascribing many hypochondriacal and hysterical affections to irritation at the origin o the inter- vulsivc affections, "^^J^ he consiQPers tetanus pend on diseases 5^^^ supported by Burse- as an example. The .am Portal sup- rius, Fcrnehus, and Belfiogerus K 1 ^ poses that slight pressing ^j£ J^ ^ ^ vulsion, and greater, paiai^i., «"i 52 406 PATHOLOGY OF THE SPINAL CORD. one passing into the other by gradual increase of the pres- sure. In the present state of our knowledge it must be confessed that these doctrines, however ingenious, are to be considered as little better than conjecture. Many facts, however, have been already related, and others are on record, which show, in connexion with diseases of the spinal cord, symptoms closely resembling those of chorea and tetanus. Hoffman mentions a boy, who, after a blow on the sacrum, was seized with a vio- lent convulsive affection nearly resembling tetanus, with loss of memory, difficult articulation, and delirium. The com- plaint continued with great severity for five days, and after- wards returned at nearly regular periods for six months. Bur- serius relates the case of a man who died of tetanus, induced by exposure to cold after intoxication; on dissection a large quantity of viscid yellow serum was found under the outer covering of the spinal cord. Frank also relates a case of " horrible tetanus," which was induced by a blow upon the spine, but he gives no account of the appearance on dissection. Several cases have been detailed in which, in various diseases of the spinal cord, symptoms occurred, closely resembling te- tanus; and this important subject has been farther investigated by Dr. Reid, in his work on Tetanus. Upon the whole, however, the truth appears to be, that though symptoms strictly tetanic do accompany various affections of the spinal cord, the disease properly to be considered as idiopathic te- tanus is entirely of a different nature, and that the pathology of it is still involved in great obscurity. 2. Colica Pictonum. 1 have referred to the case of a wo- man mentioned by Bonetus, in whom paralysis followed se- vere colic, and extensive serous effusion was found under the membranes of the spinal cord. Privatius, as quoted by Sau- vages, mentions a woman who, after suffering from violent gastrodynia for three hour^, was attacked with palsy of all the parts below the neck, and died in two months. At an early period of the disease, protrusion had taken place of the last CONCLUDING OBSERVATIONS. 407 cervical vertebra, but no account is given of the dissection. In this case, the pain was supposed to be symptomatic of the disease in the spinal cord ; and, similar to this is the view which several continental writers have taken of Colica Pic- tonum. They consider it as a real inflammation of the spinal cord, (Rachialgia Saturnia,) and on this principle they have proposed to treat it by blood-letting.* 3. Fever. Ballonius ascribes many of the symptoms of fe- ver to an affection of the spinal cord, particularly the pain in the back, tremors of the limbs, and oppression of the breathing.t A remarkable case has been quoted from Brera, in which the cord became affected in a case of malignant fe- ver; and Rachetti relates the case of a girl who died of pe- techial fever which had induced coma. On dissection, there were found evident marks of inflammation in the spinal cord and its membranes, and a quantity of puriform matter about the cauda equina ; there were also marks of inflammation in the brain and its membranes.^ 4. Epilepsy. M. Esquirol, some years ago, presented to the Faculty of Medicine at Paris, a memoir on epilepsy, in which he states that he had examined the bodies of fifteen patients who died of this disease, and found the spinal cord affected in all of them. The dissections, however, presented no uniformity of appearance. In one there were hydatids; in another the membranes were as if injected; in a third the arachnoid of the cord was of a grayish colour. In several of the cases the medullary substance of the cord was softer than natural at particular parts, and in one it was harder. In one case the spinal cord at the 11th and 12th dorsal ver- tebrae was soft and of a light brown colour. In a young wo- * Astrac, Qusstio Medico, An morbo Collie* Pictonum, rectius Rachial- gise, vensesectio ? + Ballonii Consilia Medica. + Rachetti della Struttura, delle funzioni e delle Mallatue della Mxdolla- Spinali. 40S PATHOLOGY OF THE SPINAL CORD. man, in whom the paroxysms returned with menstruation, he effected a cure by repeated .applications of moxa to the spine. 5. Hydrophobia. M. Salin seems to have been the first who conjectured that in this horrible disease the spinal cord is affected; and a case is related in Dr. Johnson's Medico- Chirurgical Journal for October, 1817, which seems to af- ford some probability to the conjecture. The case was well marked, violent, and speedily fatal. The membranes of the brain were found highly vascular, with considerable serous effusion; but the principal marks of disease were in the co- verings of the pons Varolii, medulla oblongata, and the upper part of the spinal cord. These parts are said to have formed one crust of intense inflammation, and, on the spinal cord, this crust was more intense than in any of the other parts. 6. Many cases of Dyspnoza are supposed by Frank to proceed from disease at the origin of the phrenic nerves; and difficulty of speaking and of swallowing frequently depends, according to Portal, on " engorgement" in the cervical por- tion of the spinal cord. I leave these conjectures for the investigation of the reader, and shall hasten to bring this Essay to a close, by a brief al- lusion to some points which seem to be related to the sub- ject, while they show the difficulties and obscurities which at- tend it. Several very remarkable cases have occurred to me which presented all the characters of extensive disease of the spinal cord, while nothing could be found, either in the brain or the cord, that could in any degree account for the symptoms. Case CXLVII.—A woman, aged 35, was first affected with numbness in the thumb of the left hand, which gradual- ly extended over the whole hand and arm. The limb was then partially paralytic, and was likewise affected with invo- luntary motions exactly resembling those of chorea. This CONCLUDING OBSERVATIONS. 409 continued several weeks, and then gradually ceased; and the arm recovered its healthy state. Almost immediately after this, the right hand and arm were affected in the same man- ner, and after some time also got well. The legs then be- came affected with starting, involuntary twitches, and a feel- ing in walking as if they would fly from under her to one side. The complaint went on in this manner for some time, and then terminated in complete paraplegia, with retention of urine, requiring the constant use of the catheter. She was now confined to bed for nine months, and died of extensive gangrene of the sacrum and tops of the thighs. For some time before her death she had recovered the action of the bladder. Inspection.—No disease could be discovered in the brain or the spinal cord, except that the cauda equina was of a very- dark colour, as if it had been soaked in venous blood, and there was some bloody fluid around it. The sacrum was re- markably soft, and in some places carious; and it was covered externally by a deep and extensive sloughing sore. All the other viscera were healthy. Case CXLVIIL—A medical gentleman, aged 30, who had been for several years in the navy, returned home in perfect health, and was living in Edinburgh, when he was ob- served by his friends to drag his legs awkwardly in walking. He was not himself at first sensible of it, but soon perceived a weakness and want of command over both his legs, which gra- dually increased to nearly perfect paraplegia. Some time after the affection of the legs took place, he began to lose the power of his arms, and this also increased, till he retained in them only a very feeble and unsteady power of motion: They were also frequently seized with convulsive startings, so that any ar- ticle which he attempted to hold was thrown from him with vio- lence. The legs often started in the same manner, and were thrown about with considerable violence, especially when he attempted to move them while he was sitting up. No dis- 410 PATHOLOGY OF THE SPINAL CORD. ease could be discovered in the bones of the spine, and he was otherwise in good health, until about two years after the com- mencement of the complaint, when he was seized with phthi- sis, of which he died in September 1822. I examined the body with the utmost care, and could not discover a vestige of disease either in the brain or the spinal cord. Case CXLIX.—A woman, aged about 20, a servant, sprained her back in lifting some heavy article of furniture. She felt at the time no great inconvenience; but some time after, weakness of the legs took place, which gradually in- creased to perfect paraplegia. After some time the affection extended to the arms, and she then had not a vestige of mo- tion of any of the parts below the head, except a very slight motion of some of the fingers; but the internal functions were all entire, and her speech was distinct, except that, in speak- ing, she was sometimes seized with spasmodic twitches of the lips and lower jaw. She lived in that state without any change in the symptoms, her general health continuing good, for about twenty years. In the morning she was taken out of bed, and placed in a chair so contrived as to support her in a sitting posture. Her arms were supported on a cross board which passed before her; and if, by any accident, one of them slipped from this support, she had no resource but to call the assistance of another person to replace it. Having been on one occasion left alone for about two hours, after one of her arms had thus slipped down, the hand had become extensive- cedematous. In the same manner, if her head fell forward upon the thorax, it remained in that position until raised by an attendant. Her mind was entire. She died of four days' illness, with symptoms of low typhus fever. I examined the body with the utmost care, along with Dr. Pitcairn, who had been in the habit of seeing her for several years, and we could not discover any disease, either in the brain or the spinal cord. CONCLUDING OBSERVATIONS. 411 Case CL.—A lady, aged 30, had been liable for several years to a feeling of stiffness of her neck, with an uneasy feeling in the back part of it, which made her sometimes sit with her head bent very much forward, and at other times thrown backwards; about two months before her death, these feelings increased, and were accompanied by pain, extending along both the arms; at first like rheumatic pains with stiff- ness, but soon amounting to paralysis. She had now only a very imperfect motion below the elbow, and could not raise either arm to her head; there was very slight motion of the fingers, and they were sometimes spasmodically con- tracted. The speech became thick and partially inarticu- late; she had considerable difficulty in swallowing, and she observed that there were certain positions of the neck, in which she could swallow with greater facility than in others. Her pulse was good, the other functions were natural, and the motion of the lower extremities was not at all affected. About a fortnight before her death, she became affected with dyspnoea, which occurred in paroxysms, sometimes very se- vere. An appearance of projection was now observed, with pain upon pressure in several of the lower cervical verte- bra. Issues were inserted in this place, and for a week she seemed better; she was free from dyspnoea, and the motion of the arms was considerably improved. On the evening of the 4th October, she became sudddenly comatose with some convulsion, and had a peculiar convulsive motion of the lower jaw, which was for some time in a state of constant and rapid motion, opening and shutting with violence. The arms also became more paralytic. She seemed relieved after a bleeding, but, after two hours, sunk again into a comatose state, and died suddenly. Inspection.—In the upper part of the pharynx and la- rynx there was a superficial redness like very recent inflam- mation; but, on the most careful examination, no flisease could be discovered in the brain, the spinal cord, or the bones of the spine; and all the other viscera were in a healthy state. 412 PATHOLOGY OF THE SPINAL CORD. I shall add no comment on the simple relation of these remarkable affections, but merely illustrate them by an im- portant case described by Bretanneau.* A lady, whose age is not mentioned, was affected with palsy in the little finger of the left hand, which gradually extended over the hand, and then over the arm. The left lower extremity then became affected in the same gradual manner, and after this, the arm and leg of the right side, with the exception of the thumb and two fingers of the right hand, which pre- served the power of motion. The motion of the tongue was then lost, and at last deglutition was much impeded. She preserved her intellect to the last, and expressed her- self by moveable letters, which she arranged with the thumb and two fingers of the right hand, of which she preserved the power. The duration of the disease is not mentioned. There was a small quantity of fluid in the ventricles of the brain; but the brain itself, the cerebellum, and spinal cord, being examined with the utmost care, were found perfectly healthy, with the exception of a small spot upon the tuber annulare. On the right side of this, at the depth of four lines, there was a portion three lines in ex- tent, of the colour of rust. Its centre was of the deepest colour, and its circumference irregular, gradually losing it- self in the surrounding substance; and it seemed rather harder than the other parts. The njorbid appearance, in this singular case, has a re- markable resemblance to the morbid condition of a small part of the brain, formerly referred to, and exemplified in Case CXXVIII. It is probably the result of a slow in- flammatory action, limited to a very small portion of the cord, in the same manner as we have seen it in the brain. There is reason to expect, that a very minute examination of the ^hole cord, in such cases, may discover similar * Revue Medicale, May 1826. CONCLUDING OBSERVATIONS. 413 changes of structure, calculated to throw light upon affec- tions which are at present involved in much obscurity. The following is one of the most remarkable that I have met with. A woman, mentioned by Ollivier, a servant, was sud- denly seized while making a bed, with a very strong sense of pricking in the points of the fingers of the left hand, and the points of the toes of the left foot; and half an hour after, the same parts on the right side were affected in the same manner. She continued to go about for three hours, after which she was obliged to sit down from a feel- ing of fatigue; and after sitting for some hours, she was carried to bed. Next day, there was paralysis of all the limbs, but in the greatest degree on the left side. The sensibility of the parts was not impaired. Respiration was performed with a kind of effort, and at night became very difficult. On the third day, respiration was rather improved, but there was difficult deglutition. In the evening the difficulty of breathing increased, with frequent pulse and strong action of the heart, and she died at night There was a slight appearance of infiltration of blood in the cellular tissue on the outside of the dura mater of the cord, especially about the lower part. No other vestige of disease could be discovered either in the brain or the spinal cord; and all the other viscera were in the most healthy state. I conclude this subject with a brief allusion to certain obscure and anomalous affections, which, like those now mentioned, present many of the eharae ers of d.sease of the spinal cord, though their tantalum in general .s more favourable. The affections ««> ^ « ^ racters, and the nature of them is exceeuingiy Thlmost common symptoms are various spasmodic aflcc- 21 of the limbs, or of the muscles of Urn b«*so- times resembling chorea, or even tetanus: and var.ous 53 414 PATHOLOGY OF THE SPINAL CORD. grees of weakness of the lower extremities, sometimes amounting to complete paralysis, which is often accompa- nied by remarkable spasmodic affections of the paralytic limbs. There is generally a great feeling of weakness in the back, and frequently pain, which is sometimes confined to one part, but more commonly extends in a greater or less degree along the whole of the spine. Various affec- tions of the breathing likewise occur, sometimes with at- tacks of palpitation, and various uneasy feelings in the sto- mach and bowels- The affections occur almost entirely in females, chiefly those of the higher ranks, and are ge- nerally extremely tedious and untractable. It is indeed difficult to say what treatment has any decided control over them; but the remedies which appear to be most beneficial, are, free and regular purging, or a combination of tonics and anti-spasmodics, with small doses of purgatives; strong friction; cold sponging or shower bath, and blistering on the spine. The affections commonly pass off, without leaving any bad consequences,-—sometimes very suddenly, and without any cause to which their removal can be as- cribed. One modification of these singular affections will be il- lustrated by the two following cases, which lately occurred to me in the same family. A strong and healthy girl, aged 8, of a full habit, and florid complexion, was observed to stumble frequently in walking, and occasionally to fall; and this, without any farther warning, was followed in a very few days, by perfect palsy of both lower extremities. I saw her about a fortnight after the attack, and found the limbs completely paralytic, with frequent spasmodic eon- tractions. Nothing was to be discovered about the spine, and she was in other respects in excellent health; the bowels were rather confined, but easily regulated. About a month after the commencement of this affection, her elder sister, aged 16, who had been rather delicate, and at times hyste- rical, was observed to walk awkwardly; and, in a few CONCLUDING OBSERVATIONS. 415 days, she lost entirely the use of the lower extremities. She was now for some time in a great measure confined to bed, and the affected limbs were liable to strong spasmodic contraction; her knees being drawn up to the abdomen, and the heels to the buttocks. In this manner she lay during the whole time while she was awake; but as soon as she fell asleep, the limbs were stretched out into an easy natural posture. She slept well in the night, but the mo- ment she awoke, the limbs were drawn up into their con- tracted condition. If an attempt was made to extend them, great and continued force was required, until they were brought nearly to the extended position, and then the com- plete extension took place with a sudden jerk. They now remained in this extended position for a few seconds, when they were by another sudden and painful jerk thrown back into their contracted state. This young lady had also oc- casional spasmodic affections of the arms, and of the mus- cles of the neck; but these were transient, and there was no diminution of muscular power in the arms. There was considerable uneasiness of the back, but nothing could be discovered by examination of the spine. Both cases con- tinued in the state which I have described for nearly six months, and then got entirely well. The treatment con- sisted chiefly of free and continued purging with tonics, and anti-spasmodics, topical bleeding and repeated blister- ing on the spine. In the elder of the two, one of the blisters led to the formation of a large and troublesome carbuncle on the spine, and this seemed to accelerate the ' I do not know whether the following case ought to be referred to this class: it excited my attention, as a very re- markable affection at the time when it occurred, and I have not seen another exactly resembling it. A gentiemn, aged 34, of a slender make and very active habits, « as a - fe'cted in the summer of 1815 with numbness and dimi- nished sensibility of all the extremities. In the inferior 4; 6 PATHOLOGY OF THE SPINAL CORD. extremities, it extended to the tops of the thighs, and sometimes affected the lower parts of the abdomen; in the superior extremities, it never extended above the wrists. There was along with it a diminution of muscular power. He could walk a considerable distance, though he did so with a feeling of insecurity and unsteadiness; but he could not in the smallest degree perform such motions as are re- quired in running, leaping, or even very quick walking. He was in other respects in good health. Various reme- dies were employed, without benefit; evacuations and spare diet seemed rather to be hurtful. He had continued in the state which I have described, for about two months, when he determined to try the effect of violent exercise. For this purpose, he walked as hard as he was able, five or six miles in a warm evening, and returned home much fatigued, and considerably heated. Next morning, he had severe pains in the calves of his legs, but his other com- plaints were much diminished, and in a few days disap- peared. He has ever since enjoyed very good health. These anomalous affections occur under other modifica- tions, considerably different from those which I have now described. I received from my friend, the late Dr. Mon- teith of Glasgow, a very interesting account of two cases which occurred to him under a very aggravated form. One of these, a lady, aged 22, was at first affected with vi- olent headach, accompanied by a sense of tension in the head, and a strong throbbing in the carotids, temporal ar- teries, and throughout the head; the pulse 120. Large and repeated blood-letting was employed for the first ten or twelve days; until she was "pale as paper," and exceed- ingly enfeebled, but without any relief. After four weeks, she became affected with violent pain in the lower extre- mities, which were drawn up and could not be extended, the thighs being drawn up to the abdomen, and the legs bent back upon the thighs; and every exacerbation of the CONCLUDING OBSERVATIONS. 417 headach was followed by an increase of irritation, pain and retraction of the limbs. The headach was chiefly referred to a spot upon the left parietal bone, where she had received an injury by a fall three months before. A variety of practice was employed with very little benefit; and her only relief was from blood-letting, and large doses of lau- danum, of which she sometimes took 500 drops in the course of a night. Mercury appeared at one time to be productive of some benefit; the effect, however, was only temporary, though she went through repeated courses of it. She used Prussic acid to a great extent, the warm bath, and a variety of other remedies with very little be- nefit. At the end of about three years, the limbs for the first time became so free from pain and irritation as to bear applications with the view of remedying the stiffness of the joints; and, at the end of about three years more, she was gradually restored to perfect health. This lady was not for an hour free from headach for three years, but be- sides this constant pain, she was liable to violent exacer- bations of it, lasting from a few days to several weeks. During these attacks the pulse became very strong and jar- ring and the face flushed and swelled; and the only relief she obtained was from repeated blood-letting, so that m the course of her illness she was bled from the arm ninety- eight times, besides frequent topical bleeding by leeches "T^oter' patient was a young lady of 17 whose com plaints also began with violent headach for which she underwent a great variety of treatment foi-upwards o twelve months, without any permanent benefit. On the contrary, about the end of this period, the pain rather ncreasea, and she was confined to bed in a state of ex- treme exhaustion, and suffering from constant and intense hea" ch Soon after, she first complained of pam m the " „e and this was speedily followed by a sudden a tack of Tst excruciating pain in both lower extremities, extending 418 PATHOLOGY OF THE SPINAL CORD. over every part of them, and accompanied by such increased sensibility that she could not bear the weight of the bed- clothes upon them, and the slightest touch with the finger made her scream. There was also a tenderness and morbid irritability of the trunk and upper extremities, so that she could not allow the arm to remain fully extended during the short time of feeling her pulse. From the commence- ment of this affection of the limbs, they began to be power- fully retracted, and after a short time they were drawn up close to the body; and there was severe pain extending along the whole course of the spine, where, however, no disease could be discovered on examination or by pressure. She now became much emaciated, pale and de- bilitated; the headach was rather relieved, but the limbs continued in the same state, and the slightest touch upon them, or the most gentle attempt to extend them, gave such violent pain, that, for eight months, Dr. Monteith says, she was not moved in bed six inches. At the end of four years, this lady began to improve, and to get out of bed a little daily; but at this time her legs were so much bent upon the thighs, and the knees so rigid, that no force could bring them to a right angle. At the end of three years more, Dr. Monteith's report of her was, that she could walk a short way, and was progressively improving, so that he entertained sanguine hopes of a complete reco- very. I visited this lady along with Dr. Monteith in the course of her illness, and I certainly never saw a case which gave me more the impression of deep-seated and hopeless disease. The history of these cases conveys a more distinct im- pression of this extraordinary affection than could be given by any description. Other varieties of the symptoms were observed in some of the other cases which occurred to Dr. Monteith, particularly long continued and uncontrollable vomiting, fits resembling epilepsy and catalepsy, palpita- tions and various irregular actions of the heart, and a CONCLUDING OBSERVATIONS. 419 strong and painful pulsation extending along the whole course of the spinal cord. There were also irregular at- tacks of fever, fits of colic, and severe spasms in the abdo- men, which were relieved only by large opiates. There was in general a remarkable aversion to light, and one of his patients lay in a state of almost total darkness for more than a year. In another patient, a lady of 30, the arms were affected, but not so severely as the lower extremities. This lady was confined to bed for two years, and then re- covered perfect health, which she had enjoyed for five years at the time when I received this account. In ano- ther there was such incessant vomiting that she retained nothing in the form of food, drink, or medicine, for six weeks. In this case the vision was also very much im- paired, and twice suspended for a very considerable time. Nothing was to be discovered about the spine in any of these cases, and the pain in the spine was not increased by pressure, but it was very much increased by motion, or by attempting a sitting posture. In the treatment, temporary benefit was experienced from blood-letting, very large opi- ates, and warm bath; but, upon the whole, the disease seemed gradually to wear itself out, without any mode of treatment having any sensible effect in arresting its pro- gress Even after considerable improvement has taken place, the disease is apt to relapse from very slight causes. In one of Dr. Monteith's cases, a cure was so far accom- plished in eighteen months, that a drive for a short way in a carriage was then recommended; but this produced a re- lapse, which lasted another year, and was fully as violent 38 ^affection has been described by Dr. Burns of Glas- gow; and he mentions some other symptoms as occasion- flly attending it in his observation, such as attacks_ of Dysp- noea, resembling croup, temporary loss of speech and of L pOwer of swallowing, and temporary aberraUon^mind^ He agrees with Dr. Monteith in regard to the tedious and 420 PATHOLOGY OF THE SPINAL CORD. untractable character of the disease, and confesses, that " in most cases he has not seen decided advantage from any me- dicine, beyond what was required for symptoms as they arise, time appearing the chief remedy." I find an ana- logous affection described by Dr. Guerin of Mamers, in a tract " Des Irritations Encephaliques et Rachidiennes." One of his patients, a young man of 16, had first attacks of palpitation and difficult breathing, then violent pains in the upper part of the abdomen; and, after six months, at- tacks of loss of recollection with convulsive motions of the arms, grinding of the teeth, and violent palpitations of the heart. These attacks continued to recur at uncertain periods; and, during the intervals, he did not entirely recover from the effects of them. He continued depressed and incapable of any mental exertion, unable to bear the least light or noise, and the attacks were excited by any exertion or mental emotion. The patient continued in this state for upwards of four years, and then gradually and completely recovered. The principal remedies employed were pur- gatives, topical bleeding, Prussic acid, and vegetable diet. In another case, very similar, in a young man of 20, he found benefit from the use of cold affusion. I have frequently seen in young females a slighter affec- tion, in which there was pain referred to various parts of the spine, sometimes chiefly to the lower part of it, and some- times extending upwards and downwards along the whole course of the spine. There was generally some degree of weakness of the limbs, with great disinclination to walking, sometimes with spasmodic twitching of the toes, especially in the night time. I have treated such cases by topical bleeding and blistering, without benefit; and I have generally found the most effectual treatment to be regular, but moderate purging and sea bathing. Attempts have been made, to explain these singular cases, by the doctrine of spinal irritation. But it may, perhaps, be CONCLUDING OBSERVATIONS. 421 doubted, whether this conveys any definite notion, or whe- ther it is not to be considered as a gratuitous principle, as- sumed so as to answer to the phenomena, rather than de- duced from observation. When we find, along with the com- plaints now mentioned, symptoms distinctly referrible to the spine, as pain or tenderness on a particular spot, it is fair to consider this as directing our attention to an important seat of disease; but there is no doubt that these affections often ap- pear, without any symptom that can be referred to the spine, and in many cases with sources of irritation, distinctly refer- rible to other organs. A gentleman, about whom I was con- sulted some time ago, had a severe and long-continued attack of nephralgia, which was at last relieved by the passage of a calculus ; but such a degree of inflammatory action had been excited, that for several weeks after the violence of the at- tack had subsided, he discharged purulent matter in his urine, in large quantity. In the course of the complaint, and about the time when the violent pain, which was in the region of the left kidney, was beginning to subside, he was affected with difficulty of swallowing, a sense of constriction in the oesophagus and the pit of the stomach, and spasmodic affec- tions of both upper and lower extremities, and of the left side of the face, closely resembling tetanus. These continued in a greater or less degree for eight or ten days. ' But it is chiefly in females that these anomalous spasmodic affections are met with; and in these, one of the most remark- able features of them, is the connexion which they have, even in their most aggravated forms, with the state of menstruation. The following case will illustrate this in a striking manner, and at the same time exemplify some of the various forms which are assumed by these singular affections. Case CLI.-A lady, now aged 24, in the year 1823 was first affected with numbness and partial loss of power of the r^ht arm and leg, and some time after had slight difficulty 54 422 PATHOLOGY OF THE SPINAL CORD. treatment, and returned after some months, when they affect- ed the legs and arms of both sides, and had more of the cha- racters of chorea. After another interval of several months, she became liable to attacks of blindness, which were occa- sioned by a falling down of the upper eyelids, so that she could not raise them; and when they were raised by the hand, the eyes were found to be distorted upwards. These attacks generally continued for several weeks at a time, and were relieved by cupping on the temples. With these symptoms the two first years of her illness passed. In the third year, she was affected with convulsive action of the muscles of the back, and involuntary twitches of the legs and arms, producing convulsive motions of the whole body which it is impossible to describe. These were much increased by touching her, especially on any part of her back; also by laying her upon her back, or even by ap- proaching her as if with the intention of touching her. At one time there was difficulty of deglutition, so that attempts to swallow produced spasms resembling tetanus. At other times, after lying for a considerable time quiet, she would in an in- stant throw her whole body into a kind of convulsive spring, by which she was thrown entirely out of bed; and in the same manner, while sitting or lying on the floor, she would throw herself into bed, or would leap on the top of a ward- robe fully five feet high. During the whole of these symp- toms, her mind continued entire, and the only account she could give of her extravagance was, a secret impulse which she could not resist. After a considerable time these paroxysms ceased, and she was then affected with convulsive motions of the muscles of the upper part of the back and the neck, producing a constant rotatory motion of the head. This sometimes continued without interruption night and day for several weeks together, and if the head or neck were touched, the motion was in- creased to a most extraordinary degree of rapidity. During the attacks, she could not sleep except in the sitting posture, CONCLUDING OBSERVATIONS. 423 the motion continuing during this imperfect sleep, though in a more moderate degree; but if she happened to slip down so that her head touched the pillow, she instantly awoke with a severe convulsive start, and the motion was increased to the greatest degree of rapidity. These paroxysms were relieved by nothing but cupping on the temples to the extent of 10 or 12 ounces, when the affection ceased in an instant with a ge- neral convulsive start of the whole body. She was then im- mediately well, got up, and was able to walk about in good health for several weeks,—when the same symptoms returned and required a repetition of the same treatment. Sometimes, from the violence of the motion of the head, it was impossible to cup her on the temple. In this case, the cupping was ap- plied first on the back; and by this, the motion was so far moderated, as to allow it to be applied on the temple, with- out which the paroxysm was never removed. Bleeding from the arm to the extent of faintness only moderated it for a time, but did not remove it. Another very singular feature of the affection was, that it subsided fully only when it went off in an instant with a sudden convulsive start of the whole body: when it subsided gradually as under the influence of large bleeding, it returned as soon as the faintness from the bleeding was removed. The affection went on in this manner with intervals of to- lerable health of a few weeks' duration, for about four years, besides the two years formerly mentioned. The longest in- terval was one of about three months, but even during these intervals various convulsive motions were excited by slight causes Menstruation was all along extremely irregular and very scanty, and the bowels were torpid. She was of a pale and bloodless aspect from the frequent bleedings, but not re- duced in flesh. I saw her only at an advanced period of the disease along with Mr. Gillespie, who had watched her STugh its whole progress, and by whom every variety of reatment had been employed with the utmost assiduity. AU st, in the spring of 1829, we found her under a severe 424 PATHOLOGY OF THE SPINAL CORD. paroxysm of the rotatory motion of the head; when it was determined to allow the attack to take its course, and to di- rect our attention entirely to the menstruation. With this view she began to take three grains of sulphate of iron three times a day, with two grains of Barbadoes aloes,—the aloes being afterwards diminished according to the state of the bow- els. She went on with this for nearly three weeks; the con- vulsive motion of the head continuing without intermission night and day. At length, in the middle of the night the pa- roxysm ceased in an instant, with the same kind of convul- sive start of the whole body with which it used to cease after cupping. At the same instant menstruation took place in a more full and healthy manner than it had done for many years. She has continued from that time free from complaint, and able to walk several miles, and menstruation has occurred at the regular periods, and in a full and healthy manner. I conclude this subject with the following case, which shows another form of this affection. If we were required to give a name to this modification, we could probably call it nothing but a very aggravated form of hysteria. Case CLII.—A young lady, aged 15, in October, 1828, was thrown from a horse, but did not appear to sustain any injury except a contusion of the arm, and she did not com- plain of any thing else for a week after the accident. At the end of the week she fell asleep in her chair one evening, and awoke in a state of incoherence, talking in a wild extra- vagant manner, and appearing totally unconscious of the presence of those who were about her, and entirely occu- pied with her own hallucinations. This condition conti- nued in a greater or less degree for three weeks, notwith- standing much active treatment by bleeding, purgatives, &c. The bowels were throughout remarkably torpid. She then began to recover, and went on in a state of progressive im- provement for about three weeks, when one evening she CONCLUDING OBSERVATIONS. 425 fainted, and on recovery was found to be in the same state of incoherence as before. This paroxysm continued a fortnight, and was succeeded by another fortnight of con- valescence, when the affection was reproduced by the pa- tient being told of the illness of a near relative. During the paroxysms she generally complained of in- tense headach, which was chiefly referred to the occiput; the pulse varied from 90 to 120; the tongue was white; the bowels torpid and motions unhealthy; her nights were sleepless. After the third of the paroxysms now men- tioned her convalescence was less perfect than formerly, there being generally a good deal of excitement in the evening, and very restless nights. In the end of January, 1829, after much previous irritation, she fell into a state of coma, with flushing. This continued several days, and was succeeded by a state resembling catalepsy; the eyes being continually fixed in one direction, but without per- ception; total unconsciousness of any thing that was done about her; and the jaws so firmly locked that she swallowed nothing for several days. The jaws then gradually relaxed, and she recovered the power of swallowing; after several days more she began to speak, after having spoken none for 13 days, and then went on gradually improving for some weeks. The comatose state then returned, and was succeeded as before by the cataleptic, the jaws being again rigidly contracted, and the under lip drawn between the teeth so as to be wounded; the face and neck were flushed and turgid. This attack subsided after bleeding, &c, and was succeeded by cataleptic paroxysms of a slighter kind which were excited by various causes, such as the sight ot a stranger or any degree of mental irritation In these at- tacks she became suddenly silent and motionless, the eyes open, but fixed and insensible, with total unconsciousness of everything; the hands clenched and the arms drawn towards the body. She continued in this state from a few minutes to half an hour, and generally came out of it with a scream and without any recollection of the attack, or of 426 PATHOLOGY OF THE SPINAL CORD. the circumstance which had excited it In the middle of March she became again incoherent and unmanageable, and this alternated with the cataleptic attacks till the mid- dle of April, when a new set of symptoms commenced. While lying in the cataleptic state, she would suddenly and by a convulsive motion, raise her body into a sitting posture, the head projected forward, the tongue protruded, and the countenance much distorted; the hands clenched and firmly pressed on each side of the trachea. During these attacks respiration seemed nearly suspended for some minutes, and in her convulsive efforts to breathe, she some- times raised herself into a standing posture, and required the care of several attendants to prevent her from throwing herself out of bed. These paroxysms returned frequently and at short intervals, and were relieved only by bleeding from the temporal artery. After some time they ceased, and were succeeded by the slighter cataleptic attacks ex- cited by various slight causes. It was at this period of the complaint that I first saw her along with two eminent medical men who had the charge of her: since that time there, has been no return of the violent paroxysms; and there seems to have been a gradual improvement in her general health, which cannot be ascribed to any other cause than a change of scene, and sending her regularly out into the open air. The attempt to do this at first excited the cataleptic state, and she continued totally insensible the whole time she was in the carriage. But we persevered, and this gradually subsided, so that she is now able to take a long drive without exciting it, but there is generally some recurrence of it before she returns home. The slighter paroxysms are still excited by the sight of a stran- ger, or by any cause of mental agitation. During these her body becomes motionless, but without losing her ba- lance, though she be sitting on a chair without leaning to the back of it, and even in some instances while she is standing. The eyes are open, fixed, and insensible; the arms generally rigid, but sometimes relaxed, and the at- CONCLUDING OBSERVATIONS. 427 tack continues from a few minutes to half an hour. Late- ly she has been seized occasionally, while walking, and has continued to walk on steadily, leaning on the arm of another person, and even walking alone, and has come out of the fit without stopping. She has also been repeatedly seized while playing on the piano, and has continued to play with perfect correctness, but repeating a certain part of a tune, and never going on beyond a particular point. This she has continued to do for ten minutes at a time, during which period she was totally unconscious of any ex- ternal impression. On one occasion she was playing from the book a piece of music which was new to her, and had played a part of it when she was seized with the cataleptic attack. During the paroxysm she continued to play this part, and repeated it five or six times in the most correct manner; but when she recovered from the attack, she could not play it without the book. The catamenia, in this case, have been rather irregular, and at times scanty, but have occurred in a very natural manner, several times during her illness, which has now continued ten months. I make no apology to practical men for these long details, as the affections are of a very uncommon kind, and as it is impossible to convey any idea of them by a general descrip- tion. There are other modifications presenting very singular characters, but I must allude to them very briefly. A young lady, whom I saw with Mr. William Wood, along with some symptoms resembling chorea, was liable to paroxysms, in which she screamed out the sound, echum, echum, echum, with great rapidity, and in a tone of voice that was heard over every part of a large house. These paroxysms often continued for one, two, and even three hours at a time, and occurred repeatedly during the day, and sometimes m the night They were excited by any sudden noise, or the sight of a stranger; and in the night time not unfrequently by the striking of a clock. Her mind was quite entire, but she had no control over the affection, except that during the paroxysm 42S PATHOLOGY OF THE SPINAL CORD. she could change the sound when she was requested to do so, and substitute any other word that was suggested to her. The affection went on for many months, and then gradually sub- sided. We could scarcely say that medical treatment was of any avail. It consisted chiefly of a long-continued course of purgatives. For a considerable time after her recovery, though she was not at all affected by her disorder being talked of, she showed the greatest dread of the sound echum being repeated in her hearing. Another lady, whom I have seen with Dr. Poole, is liable to paroxysms of rapid and laborious breathing, with a loud shrill sound, and the appearance of the utmost distress, as in the most aggravated form of croup. They come on without any warning, when she is in perfect health, and if not relieved, continue for days together. They are relieved by nothing but blood-letting, but in several instances, a bleeding of three or four ounces has been sufficient; and on one occasion, the attack was removed by a puncture of the arm, when no blood was obtained, or only a few drops. A case of much interest has been related by Dr. Follot of Namur. A strong country woman being much terrified during the flow of the menses, the discharge was suddenly suppressed. After four months, she experienced creeping sensations, spasms, and involuntary motions of the lower extremities: and in the following month, the limbs became forcibly bent, so that the heels touched the buttocks, and every attempt to extend them produced the most acute suffering. These symp- toms continued five days, and then subsided; but they were renewed at the same period in the succeeding month, and subsided after the same duration, but left a degree of para- plegia. The attacks were afterwards moderated by repeated topical bleeding, vapour bath, &c, but the affection continued in a greater or less degree for six or seven months. Men- struation having then taken place in a full and healthy man- ner, her complaints entirely disappeared.* * Medical Gazette, vol. i. APPENDIX PART FOURTH. OUTLINE OF THE DISEASES OF NERVES. Nearly allied to the pathology of the spinal cord, is ano- ther subject of very great interest, the pathology of nerves. This subject is entirely in its infancy, but the investigation seems to promise very interesting results. From what we already know, there is every reason to believe, that nerves are liable to diseases analogous to the diseases of the brain and of the spinal cord, which may affect them either in their substance or in their membranes, and are probably the source of several diseases which are at present involved in much ob- scurity. In as far as this subject has hitherto been investigated, the following may be considered as the principal idiopathic dis- eases of nerves which have been observed. 1. A uniform dark red colour of the nervous substance, occupying a defined space, perhaps an inch or two in extent. This was observed by Martinet,* in the median nerve, in a case in which there had been violent pain of the fore-arm, followed by palsy. Repeated blisters removed the paralytic affection, but, as soon as the blisters healed, pain returned followed by palsy. In a similar affection of the right sciatic nerve, accompanied by palsy of the limb, he found a diseased portion of nerve enveloped in a quantity of gan- grenous cellular tissue. In another case he found a dis- eased portion of the crural nerve, which was an inch and a half in extent, enlarged to about double its natural size. This * Revue Medicale, Juin, 1814. 55 43Q OUTLINE OF THE DISEASES OF NERVES. portion was of a violet red colour, and strewed throughout with small ecchymoses each about the size of a pin's head. II. Serous or bloody effusion within the sheath of the nerve, penetrating the substance of the nerve, and separating its fibres from each other. This appearance was found by Martinet in the sciatic nerve of a man who died of pneumo- nia; he had been affected with violent pain in the posterior part of his thigh, aggravated by the least motion so^as to make him cry out. III. Pus effused in the same manner among the fibrils of the nerve. This was found in the sciatic nerve by Martinet, in a man who died of disease both in the head and in the ab- domen, and who had been affected during the latter part of his illness with violent pain in the course of the sciatic nerve. The cellular texture surrounding the diseased portion of the nerve was also penetrated by pus. He found the same ap- pearance in a young man who died of consumption, and who had been affected for two months with lancinating pain, and a painful feeling of numbness extending from the ham to the top of the thigh. IV. Ramollissement of the nervous substance.—A man mentioned by Descot* died in the Hotel Dieu, after he had been for six months blind of one eye. The optic nerve was found reduced through half its extent to a liquid matter of a white colour. V. Ulceration of the substance of the nerve was observed by Mr. Swan in connexion with a fungous ulcer on the leg. There had been such violent pain of the whole leg and thigh, as to render amputation necessary, and in many parts of the limb, the nerves were found very much enlarged.! VI. Small tumours attached to nerves, and productive of violent symptoms, have been described by various writers. In a remarkable case by Portal, a woman was cured of epi- lepsy by the removal of one of these tumours from the thumb. The slightest pressure upon it gave great pain, and frequently * Descot, Sur les Affections Locales des Nerfs. f Swan on the Local Affections of the Nerves. OUTLINE OF THE DISEASES OF NERVES. 431 brought on an epileptic attack. The removal of such a tu- mour however from one of the axillary nerves by Sir Everard Home, terminated fatally; and the safer mode of treating such affections appears to be to remove the portion of nerve entirely to which the tumour is attached, when the nerve is so situated as to render such an operation advisable. Small tu- mours or tubercles have also been found on internal nerves. Sedillot found one in the optic nerve, in a case of amaurosis; and Berard has described a black tumour as hard as scirrhus developed in the substance of the diaphragmatic nerve. The man had been asthmatic, but he had also slight emphysema of the lungs. These tumours are generally very small; but there is ano- ther species of tumour which grows to a considerable size. One mentioned by Mr. Pring,* the size of a pigeon's egg, was cut out from the arm, by dividing the nerve above and below. On cutting into it an expansion of the substance of the nerve seemed to form an imperfect cyst, which contained a medul- lary and fatty matter, and the filaments of the nerve were continued over it. There had been great numbness and los3 of power of the arm, but it gradually improved after the ope- ration.! VII. Nerves have been found both very much enlarged and very much diminished in size; and they have been in a few instances found with the nervous substance destroyed, the membrane at the part forming an empty canal. But these points have not yet been sufficiently investigated. Few opportunities have as yet occurred of ascertaining the condition of the nerve in those interesting cases of local para- lysis which have been so beautifully illustrated by Mr. Charles Bell! and his lamented friend the late Mr. Shaw. It is probable that there is either an inflammatory action m the nerve itself, or its coverings; orthat the nerve is affected by * Pring on the Nervous System. leases * For a very full and able account of these tumours, and other diseases of Lrves! I refer to a paper by M, William Wood, in the Transacts of the Medico-Chirurgical Society of Edinburgh, vol. u. 432 OUTLINE OF THE DISEASES OF NERVES. disease of some of the parts through which it passes. The only case in which I have had an opportunity of examining the parts, since I was acquainted with the discoveries of Mr. Bell, was in a woman about 40 years of age, who died of or- ganic disease of the stomach. About a fortnight before her death, she was seized with twisting of the mouth and paraly- sis of the orbicularis of the left eye. She had afterwards considerable indistinctness of speech, and, before her death, there was inflammation of the left eye, with an evident ten- dency to sloughing of the cornea. A small hard tumour was felt under the ear, deeply seated betwixt the angle of the jaw and the mastoid process. On dissection no disease could be discovered in the brain. The tumour under the ear was found to be the size of a small bean, very firm, of an ash-co- lour; and, when cut across, it discharged thin puriform sanious fluid from minute cells in its substance; it lay directly above the facial branch of the portio dura; and there was consider- able appearance of inflammation in the cellular structure sur- rounding the nerve; but I could not discover any deviation from the healthy structure in the nerve itself. I thought it was diminished in size at the place where the tumour lay over it, but in this I might be mistaken. In a case by Descot, connected with extensive suppuration and caries of the au- ditory portion of the temporal bone, a part of the portio dura was entirely destroyed; and in a case by Billard, connected with an unhealthy abscess of the parotid gland, the course of several of the nervous branches was interrupted by destruc- tion of part of their substance. An epileptic patient, men- tioned by Serres, had inflammation followed by opacity of the right eye, loss of feeling of the conjunctiva, and insensi- bility of the right nostril, and right side of the tongue. He died of an affection of the brain; and, on inspection, the fifth pair of nerves, at its origin, was found yellow, softened, and reduced to a state almost gelatinous. The important practical application of the discoveries of Mr. Bell is, that there may be paralysis of the muscles of one side of the face, producing distortion of the mouth OUTLINE OF THE DISEASES OF NERVES. 433 with inability to shut the eye-lids, without disease of the brain, and consequently without danger. This affection depends upon a disease limited to the portio dura of the 7th nerve, and may be produced by inflammation of the ear or the parotid gland, or tumours compressing the nerve on any part of its course. The most common example of it seems to originate in a kind of rheumatic inflammation produced by cold, especially by exposure to a current of cold air, as when a person has sat long, or has slept, opposite to an open window, or has sat in a carriage with a cold wind blowing on one side of his head. It is to be treated chiefly by local remedies, as topical bleeding, blistering, and the application of warm water or steam. In this man- ner it is often speedily removed, but in some cases proves tedious; and does not go off entirely for several months. The affection is of course still more untractable, or even permanent, when it depends upon a permanent cause, such as tumours compressing the nerve, or destruction of a por- tion of the nerve by wounds or extensive suppurations. There is also a very formidable modification of it which depends upon disease of the temporal bone. The character by which these cases are distinguished from paralysis depending upon disease of the brain, con- sists chiefly in the sensibility of the parts remaining unim- paired. The loss of motion also is confined to the muscles of the face and eye-lids, and does not affect those of the jaw. These peculiarities arise from the remarkable facts dis- covered by Mr. Bell, Mr. Shaw, Mr. Mayo, and others, that the portio dura of the 7th is a nerve of motion only, sup- plying the muscles of the face and the orbicularis of the eye, but not the muscles of the jaw; and that the sensibili- ty of all these parts, and the motion of the muscles of the jaw are derived from the 5th, which, having a double ori- gin, is a nerve both of sensation and motion. An impor- tant distinction, however, is to be kept in mind in regard to the paralysis of the eye-lids which occurs in these cases, namely, that it is the inability to shut the eye that arises 434 OUTLINE OF THE DISEASES OF NERVES. from the affection of the portio dura of the 7th. The dropping of the upper eyelid and inability to raise it, is a disease entirely of a different nature; it depends upon an affection of the 3d nerve, and consequently gives more reason to suspect diseases within the head. When, therefore, we find paralysis and distortion of the face, with loss of sensation of the parts, we have reason to suspect disease within the head, the portio dura of the 7th and the 5th being both affected. But when we have the pa- ralysis without diminution of sensation, the disease de- pends upon an affection of the portio dura alone, and may be entirely without danger. Such cases, however, are not to be treated lightly, but the cause of them ought to be carefully investigated; for if there be any reason to suspect that the affection depends upon disease of the temporal bone, it may come to be attended with danger by inflamma- tory action spreading inwards to the dura mater or brain. There is another modification also which requires to be watched with anxiety, namely, when the affection is ac- companied with deafness; as this gives reason to believe that both portions of the 7th nerve are affected, and conse- quently to suspect an internal cause. A very interesting case of this kind occurred lately in the Infirmary of Edin- burgh, under the care of Dr. Gregory. Two years before his death, the man had received a blow on the right ear from a stone, after which he had a purulent discharge from the ear for six months. He then gradually lost the hear- ing of that ear, and about the same time the right side of his face became paralytic without any diminution of sensi- bility, and the action of the masseter and temporal muscles was unimpaired. Without any farther change of these com- plaints, he died of phthisis in April, 1829. The petrous portion of the temporal bone was found most extensively de- stroyed, leaving an excavation which contained fetid puru- lent matter and portions of dead bone. The 7th nerve was traced from within to the margin of this excavation where it terminated, and the portio dura, in the same manner from OUTLINE OF THE DISEASES OF NERVES. 435 without, the intermediate portion being destroyed. The parts of the nerve that remained seemed entirely healthy. The brain and dura mater were sound. For some time be- fore his death the patient suffered greatly from dyspnoea, during the severity of which the alae of his left nostril were in strong and constant action, while those of the right were perfectly still. If this man had not been cut off by the dis- ease of his lungs, the affection of the temporal bone would probably have terminated fatally in no long time, by in- flammation of the dura mater. I am indebted to Dr. Christison for a very important case which occurred to him in the Infirmary of Edinburgh in the beginning of the present year. The patient, a man of 30, was seized in the beginning of 1825 with acute pain, referred to a circumscribed spot on the left temple. About a week after he had loss of speech followed by coma. He came out of this with loss of the memory of persons, but gradually recovered and was well in less than two months. In the end of 1827, he was again seized with pain in the temple, accompanied by deafness of the left ear and squint- ins of the left eye. The deafness was permanent; the pain and squinting subsided after three or four months; but re- turned after two or three months more accompanied by 1n- and right shoulder; and these were followed y reten .on of urine and perfect paraplegia. He had now the usual pa- rtly c state of all the parts supplied by the portio dura of ^he left side, with deafness of the left ear, distortion of the eft etTnwards towards the nose, and frequent spasmo ic I t ** in w bv which it was drawn to the right side; *?^dWin' Ite'of coma in February 1829. On in- & ctionherwaound immediately behind the left tern- 436 OUTLINE OF THE DISEASES OF NERVES. dura mater above the pars petrosa of the temporal bone, and the left side of the tentorium was also very much thick- ened, and presented on its inferior surface several tubercu- lar elevations. The thickening of the dura mater was great- est at the part where it is perforated by the seventh nerve, and the sixth nerve was also involved in the disease. The portio mollis of the 7th was, for a few lines previous to its entrance into the meatus, of a reddish gray colour, and nearly gelatinous consistence; the portio dura seemed smal- ler than usual. In the substance of the right hemisphere, nearly on a level with the ventricle, there was a tubercle the size of a French bean; and there was a small cyst in the right corpus striatum. In the posterior cornu of the right ventricle, there was a peculiar appearance, as if a portion of it had been obliterated by adhesion; cutting off a very small cavity about the size of a lemon seed, which com- municated by a narrow opening with the ventricle, and presented at each extremity a yellowish line or raphe re- sembling a cicatrix. No appearance of disease could be detected in the contents of the spinal canal. This case is one of great interest, besides the point which it is here introduced to illustrate. In particular, it presents a most important example of chronic inflammation of the dura mater, affecting three distinct portions of it, and ac- companied by three distinct classes of symptoms. The intense and long-continued pain of the left temple, which was a prominent feature of the case at various periods, ap- pears to have been connected with inflammation of a defined portion of the membrane in that situation. The remarkable affection of the functions of the seventh nerve, we may distinctly refer to the diseased condition of the same mem- brane where it is perforated by the nerve; and the distor- tion of the eye inwards, from paralysis of the abductor muscle, we trace to the sixth nerve being involved in the disease. No cause appears to which we can refer the para- plegia, except the disease of the tentorium, no morbid ap- pearance having been discovered in the spinal cord or its OUTLINE OF THE DISEASES OF NERVES. 437 membranes after the most careful examination. I have for- merly referred to certain difficulties in the pathology of paraplegia, and the obscurity attending those cases in which it has been ascribed to disease within the head, from the spinal cord not having been in general examined.* Dr. Christison's case, therefore, is one of much importance in this inquiry. The functions of the 5th nerve, as has been mentioned, appear to be, to give sensation to all the parts about the face, and motion to the muscles of the jaw; and a variety of singular phenomena arise from affections of this nerve, or particular branches of it. Thus, in the organs of sense, there may be loss of common sensation, without any af- fection of their proper senses depending upon their peculiar nerves. A young lady, mentioned by Mr. Bell, lost en- tirely sensation in the ball of the eye, without any diminu- tion of vision; and there have been several instances of the membrane of the nose becoming insensible to common sti- muli, while the smell was little impaired. In the same manner, there may be loss of sensation in any limited part, from disease or injury of a particular branch of the 5th, as in a striking case'mentioned by Mr. Bell. A gentleman, after havin°- a grinder very awkwardly extracted from the lower jaw, on putting a tumbler to his lips to rinse his mouth, exclaimed, " You have given me a broken glass. He had lost entirely the sensation of half the lip, from de- struction of the branch of the 5th which passes along the lower jaw, and the affection was permanent. The motion of the parts, depending on the portio dura of the 7th, ot course was unimpaired.! A remarkable circumstance connected with the affections of the 5th nerve, is the tendency to inflammation and slough- ins in parts which have lost their sensibility-particularly in Z eye A very instructive case of this kind occurred to my I Mr! S Le'turcs, as reported in the Medical Gazette, vol. ' 56 438 OUTLINE OF THE DISEASES OF NERVES. friend Dr. Alison. The patient had loss of common sensation on the left side of the face, the left nostril, and left side of the tongue, with insensibility of the ball of the eye, and occasional bloody discharge from the left nostril; and was liable to at- tacks of pain occasionally accompanied with fever, during which the pain was chiefly referred to the insensible parts. There were frequently attacks of inflammation of the left eye, with dimness of the cornea, which were relieved from time to time by the usual antiphlogistic means; but at the end of two months, a line formed round the base of the cornea, which at length sloughed out, and the contents of the eye were entirely discharged. The muscles of the left side of the jaw were paralytic, and felt quite flaccid when the pa- tient chewed or clenched the jaws, but the motion of the muscles of the cheek was unimpaired. After the destruction of the eye, the paralytic symptoms remained stationary for a year or more; there was then a violent return of headach with fever, and death in a state of coma after an illness of a fort- night. On inspection, there was found considerable ramol- lissement of some of the central part of the brain. The 5th nerve of the left side, on being traced backwards from the ganglion, was found, close to the ganglion, to be of a very dense texture; but beyond this it was much wasted, and at its junction with the tuber annulare, nothing but the mem- brane seemed to remain. In another case of Dr. Alison's there was loss of sensation of the left side of the face, followed by inflammation and sloughing of the eye-ball; after which the sensibility of the parts returned. The patient was before the appearance of these symptoms, and has since continued, liable to severe headach and epileptic fits. The loss of sen- sibility continued about six months. A remarkable combination of symptoms occurred in a case related by Mr. Stanley.* There was hemiplegia of the left side, without loss of sensation in the arm and leg, but in the left side of the face both sensation and motion were entirely ' Medical Gazette, vol. i. OUTLINE OF THE DISEASES OF NERVES. 439 lost. In the left side of the tongue, sensation was lost, but motion remained. The mucous membrane of the left nostril was always of a deep red colour, and there were frequent discharges of blood from it. The conjunctiva of the left eye became deeply injected; this was followed by opacity and ulceration of the cornea, and at last by total disorganization of the eye. There was total loss of hearing in the left ear. There were frequent attacks of erysipelas, which were en- tirely confined to the paralytic parts of the face. The patient had been long affected with headach, and at last died two months after the commencement of the paralytic symptoms. A tumour was found in the left side of the tuber annulare, which compressed the origin of the 5th and 7th nerves against the -base of the skull. The tumour was the size of a walnut, of a firm consistence, and brown colour, and extended into the left crus cerebelli. To affections of the nerves, may probably be referred, certain obscure and severe disorders of a nervous kind, some of which have supervened upon slight injuries, and others have come on without any obvious cause. A young lady mentioned by M. Verpinet,* received a slight wound with the point of a sword on the inferior and outer part of the fore-arm. It very soon healed, but most violent pain continued in the fore-arm, wrist, and hand, accom- panied by convulsive motions of the arm, and loss of the voluntary power of the wrist and fingers. The affection resisted every mode of treatment for two years, and then got speedily well after the application of the actual caute- ry to the cicatrix of the original wound. In a lady, men- tioned by Mr. Swan,t a slight wound on the thumb was followed by numbness, pain, convulsive motions of the arm, and spasms, which occasionally affected the opposite arm and sometimes the whole body. In this case the af- ect on seemed gradually to wear itself out, though she * Join-, de Med. vol. x. f Swan on Local Affections of Nerves. 440 OUTLINE OF THE DISEASES OF NERVES. was not entirely free from uneasiness at the end of seven years. A very violent case of the same kind, described by Mr. Wardrop,* was cured after twelve months by am- putation of the finger. In a similar case by Larry, which followed a wound, a portion of the nerve was removed, without complete success, though the disease was very much alleviated. In a singular case by Sir Everard Home,t a gentleman received a violent sprain of his thumb, by the weight of his body being thrown upon it, in saving him- self when nearly thrown off, by a sudden motion of his horse. He was afterwards liable to paroxysms, in which his thumb was first bent in towards the palm of his hand; a spasm then took place in the muscles of the arm, after which he became insensible, and continued so for about a quarter of an hour. The attacks returned frequently in the arm, but it was found that the pressure of a tourniquet prevented the insensibility. A nerve in this case was di- vided without success. The tourniquet lost its effect in arresting the spasms, and he died suddenly after three months, but there was no examination of the body. In the Medical and Physical Journal, Mr. Jeffries has described a remarkable case of a violent neuralgia of the face, which was cured by the extraction of a small frag- ment of china, which had been lodging there for fourteen years; and M. Descot mentions a case in which a very se- vere affection of ten years' standing was removed by the extraction of a carious tooth. A young lady, mentioned by Mr. Pearson, was seized, without any obvious cause, with pain in the thumb, accompanied by a morbid sensi- bility of the part; the affection gradually spread over the arm, and was accompanied by loss of nearly the whole muscular power of the extremity, with morbid sensibility of the integuments, and a strong contraction of the fingers, so that the points of the nails were forcibly pressed against * Med. Clrir. Trans, vol. viii. t Phil. Trans. 1801. OUTLINE OF THE DISEASES OF NERVES. 441 the palm of the hand. The fingers were not under the control of the will, and every attempt made to extend them was accompanied by insupportable pain. The joint of the elbow also was contracted, and voluntary motion was near- ly lost over the whole extremity. It was also very much diminished in size, while the morbid sensibility of it was inexpressibly distressing. After some time the other arm was slightly affected in the same manner, and she had like- wise pain and great debility of both the lower extremities. After this affection had continued about a year, it got well under the use of a liniment composed of olive oil, turpen- tine, and sulphuric acid. This produced most severe ery- sipelatous inflammation, which, beginning upon the affect- ed arm, extended afterwards over the whole body.* Little has hitherto been done on this curious and inte- resting subject, but it certainly promises most important results, when it shall be more extensively cultivated. For we have every reason to believe, that both the nerves them- selves, and the investing membrane, are liable to affections which may be the source of many obscure diseases. It is now upwards of seventeen years since I first saw a girl, aged at that time about 18 months, and previously enjoy- ing excellent health. She had been left for some time sit- ting upon damp grass, and was immediately seized with fe- ver, accompanied by such a degree of oppression as led to an apprehension of an affection of the brain. These symp- toms, however, passed off in a few days, and, upon her re- covery from them, it was found that she was ent.rely para- lytic in the right lower extremity. She has from that time enjoyed uninterrupted health, and is now a tall and strong young woman, but the right lower extremity has continued entirely paralytic. It is also a great deal sma ler than the opposite extremity, and several inches shorter. All the joints are remarkably relaxed, and the muscles flaccid; but there is no other appearance of disease in any part of it, or in the s^.__Soinc^^^ » Med. (Jhirurg. Trans, vol. viii. 443 OUTLINE OF THE DISEASES OF NERVES. about a young man, aged 14, who had nearly lost the mus- cular power of the upper part of both his arms, accompa- nied by a most remarkable diminution of substance of the principal muscles. The deltoid and biceps are reduced to the appearance of mere membranes, and the same affection extends in rather a less degree to the muscles upon the scapula; the muscles upon the fore-arm, however, are full and vigorous. No disease can be discovered about the spine, and in other respects he is in perfect health. The affection has come on gradually, and cannot be traced to any cause. It is impossible, I think, to explain such cases as these, except upon the principle of local affections of nerves, which are at present involved in much obscurity. There are various other affections which can only be referred to the same subject, and which present some very singular phenomena, though the facts relating to them have not yet been brought together in any connected form. Some time ago I was consulted about a singular disease of this nature, which occurs in paroxysms, and affects in the same manner two individuals of one family, a young lady of 25, and a young man of 22. The lady describes the attack in the following manner. She is first affected with blindness of the right eye, which comes on gradually as if a cloud passed slowly over the eye; about a quarter of an hour af- ter this, she feels a numbness of the little finger of the right hand, beginning at the point of it, and extending very gradually over the whole hand and arm, producing a complete loss of sensibility of the parts, but without any loss of the power of motion. The feeling of numbness then extends to the right side of the head, and from this it seems to spread downwards towards the stomach. When it reaches the side of the head, she becomes oppressed and partially confused, answers questions slowly and confused- ly, and her speech is considerably affected; when it reaches the stomach she sometimes vomits. The feeling of numb- ness then begins to subside, and as it goes off, she is seized with violent headach, which continues for several hours, OUTLINE OF THE DISEASES OF NERVES. 443 and leaves her for a day or two feeble and languid. The progress of the feeling of numbness, from the little finger to the stomach, sometimes occupies several hours, and the common duration of the whole paroxysm is about twenty- four hours. The frequency of its occurrence varies from a few days to several months; she has been liable to it for several years, but in the intervals betwixt the attacks she enjoys perfect health. Her brother, who is 22 years of age, is affected almost exactly in the same manner, and he has been liable to the paroxysms for many years. He is a banker's clerk, and in the intervals between the attacks enjoys perfect health. When he feels the commencement of the attack, he hastily brings to a conclusion any business in which he happens to be engaged,—gives distinct in- structions to another of the clerks in regard to the state in which he leaves the affairs of his department; then walks home, goes to bed, and soon after becomes insensible. Next day he is in his usual health, except a considerable degree of languor. These singular cases are under the care of Dr. Gibson of Montrose, and they seemed to derive benefit from a course of purgatives, followed by a course of sulphate of quinine, combined with small quantities of rhubarb. Another of the family, a stout young man of 20, has lately had several attacks of a similar affection, though in a slighter degree. In a farther report received while this second edition was in the press, Dr. Gibson informs me that the affection has continued, but that the attacks have been less frequent and less severe; and that on several occasions they seem to have been lessened in violence and shortened in duration by emetics. The affections of internal nerves present a subject of still greater difficulty, and the observations that have been made in regard to them are at present far from being sa- tisfactory. Lobstein* thinks he has ascertained the exist- ence of inflammation of the great sympathetic nerve; and * Dc Ncrvi Sympathetic Fabrica, usu, ct Morbis. 444 OUTLINE OF THE DISEASES OF NERVES. to this source he refers many obscure diseases, such as, vio- lent hysterical affections, sympathetic affections of the heart, spasmodic cough, colica pictonum, angina pectoris, and many obscure affections of the stomach and bowels. In the same manner, he explains the fatal effects which are produced by blows upon the stomach, and the severe symptoms both in the head and in the general system, which often arise from worms, and from other disorders of the bowels. In a lady who died of urgent vomiting, with burning pain in the spine, and in the right hypochondrium, he found the semilunar ganglion in a state of intense in- flammation, and the lower part of it livid. In a boy who died with great oppression of the chest; and distention of the epigastrium, supervening upon the retrogression of a miliary eruption, he found deep inflammation of a part of the trunk of the left intercostal nerve, and of the ninth and tenth thoracic ganglia. These speculations must be received with much caution, especially as nothing is more precarious than morbid ap- pearances, consisting of mere change of colour of parts, without any of the actual results or terminations of inflam- mation. We must forbear to speculate where we have not facts before us, but it appears extremely probable that there are diseases of internal nerves which may be the source of important morbid phenomena. Descot exposed the par vagum upon the neck of a dog, and bruised it on both sides slightly with a pair of pincers; the wound healed favoura- bly, but the animal was affected with general tremors, dif- ficult and laborious breathing, vomiting, great debility and wasting. The vomiting subsided, and the other symptoms were diminished, but he had not recovered a natural state of his breathing, when he was killed at the end of three weeks. The internal organs were all healthy. The nerve on the left side, where the injury had been inflicted, ap- peared slightly increased in size, and was of a yellowish colour; and that on the right side appeared more decided- ly enlarged, highly injected, and adhering to the neigh- bouring parts. ARRANGED SELECTION OF CASES ILLUSTRATIVE OF THE PRINCIPAL MODIFICATIONS OF ORGANIC DISEASES OF THE BRAIN, INTENDED TO FORM A SUPPLEMENT TO PART III. OF THIS TREATISE. SECTION I. First Class.—Long continued headach, terminating at last by coma or by gradual exhaustion. {See page 331.) Symptoms. Case I.—A woman of 35—fixed pain in the back of the head—walk tremulous and unsteady, like a per- son balancing1 a burden on the head —much throbbing in the head—hys- terical symptoms. Remarkable re- mission of all the symptoms after the formation of an abscess in the axilla; but the pain returned when it healed, and increased to tremendous severi- ty, and with remarkable remissions. From two o'clock in the morning till two in the afternoon she was in the greatest agony, lying with her eyes closed, the eyebrows contracted, the hands clenched, and the head immo- veable in one position, unable to bear the least noise, or to move a muscle. After two P. M. the symptoms gra- dually remitted—she took food, and about nine fell asleep, and slept till two, when the paroxysm recurred. As the disease advanced, the interval became shorter, and for a fortnight before her death the pain was con- stant—senses entire to the last—palsy of the left leg for three days before death—duration of the case fourteen months. 57 Morbid Appearances. A tumour at the base of the cere- bellum, growing from both lobes of it, and descending within the dura mater into the spinal canal, as low as the sixth spinal nerve. It was soft like fetal brain, and seemed to grow out of the interior of the cerebellum. As it lay along the spinal cord, it rest- ed upon the origin of the nerves, but did not involve them in its sub- Dr. Latham, Med. and Phys. Jour. July, 1826. 446 SUPPLEMENT TO PART III. Symptoms. Case II.—A man, aged 40—violent pain in the back of the head, ceasing at times, but returning, and accom- panied with vomiting, and always re- ferred to the same spot, much re- lieved at different times by bleeding and by salivation, but always recurred with great violence, and was referred to a single point at the junction of the temporal and occipital bones— frequent vomiting—impaired vision. Died suddenly in one of the attacks of pain—duration of the complaint about a year. Case IV.—A man of 50—constant pain of forehead, with frequent vo- miting. Other functions healthy. Coma for three days before death. Death in three months by gradual exhaustion. Case V.—A man, aged 55—lan- cinating pain in the right side of the head—aggravated at intervals. Af- ter two months coma and death. Case VI.—A boy of 14—severe headach for two months—then con- vulsion, followed by coma and death on the 8th day. Morbid Appearances. In the left lobe of the cerebellum, a tumour an inch long and ten lines in breadth, composed of about nine alternate layers of a chalky matter, fluid albumen, and a very firm matter with the properties of albumen, which grated under the knife. It was enclosed in a cavity which also contained a tough glutinous matter, and the surrounding substance was like rancid bacon. Prof. J\'asse App. to Germ. Trans. of Dr. Abercrombie's Papers on the Brain. A tumour two inches long arising from the cella Turcica, covered by the dura mater. Ventricles distended with serum. Communicated by Mr. William Brown. A mass as hard as scirrhus, four inches long, and between two and three broad, in the substance of the right hemisphere, on the outside of the thalamus. Internally it contained small cells full of gelatinous matter. Bouillaud Traitd de VEncephalite. A tumour the size of a walnut of a rose-colour and a fatty consistence behind the posterior part of the me- dulla oblongata; another smaller in the left lobe of the cerebellum. Se- rous effusion-—diseased mesenteric glands—ulceration of the small intes- tines. Merat Journ. de Med. torn. X. Case III.—A young man of 20— violent pain of the forehead—it oc- curred in paroxysms, which gene- rally continued four days, and were followed by intervals of partial relief of about the same duration. After two years died suddenly in the night from convulsion. A tumour the size of a pigeon's egg, hard in the centre, and exter- nally soft, in the substance of the cerebellum other parts health v. Planque Biblioth. III. 348. CASES OF ORGANIC DISEASES OP THE BRAIN. 447 Symptoms. Case VII.—A man, aged 35—-vio- lent headach, which was sometimes so severe as to oblige him to remain for a considerable time in one pos- ture, incapable of the least motion— consumptive symptoms—death after seven months in a state of complete marasmus. Morbid Appearances. Three ounces of fluid in the ven- tricles, a firm tumour the size of pigeon's egg in the upper and mid- dle part of the right hemisphere, enclosed in a reddish sac, internally of a yellowish colour. A larger tu-. mour of the same appearance in the left lobe of the cerebellum—exten- sive disease of the thorax and abdo- men. Merat, ut Supra. Case VIII.—Man of 58—liable for 15 years to attacks of acute pain in the right temple, extending over the right side of the head and face—first attack continued three weeks—and it aft«rwards returned in paroxysms of very uncertain duration, and at very irregular intervals. After fif- teen years, a more severe attack, which continued two months and ended in coma and death. For some days before death, had palsy of the left side, and of the right eye- lid. On the outside of the right thala- mus, and on a level with it, a tumour in the substance of the brain of a red- dish gray colour, four fingers breadth in lengtli, and two or three in breadth, partly hard, and partly in cysts containing a gelatinous matter. Andral. Jour, de Phys. Case IX.—An officer, aged 33— slight pain and confusion of the head with impaired appetite. Af- ter ten weeks, nausea and pain in the eyeballs. He was then wounded in the head—lost much blood, and the bone exfoliated, and he was much better for more than a year. Then headach—watchfulness—flushing— and ophthalmia. Recovered after three months, but was never free from headach. It gradually in- creased; was sometimes referred to a spot on the occiput, and sometimes througli the whole head. Was much aggravated by motion, which produced a painful jarring in his head, and much increased by going to stool—pain at last excruciating, with numbness of the left hand- then sudden delirium—coma and death in three days—duration of the complaint three years. Three ounces of fluid in the ven- tricles—in the seat of the pineal gland, a little to the right side, a tu- mour the size of a nutmeg—inter nally it was like cheese, but organ- ized. Ramollissement of the cere- bellum. Sir G. Blane, Trans, of a Soc. vol. ii. 448 SUPPLEMENT TO PART III. Symptoms. Morbid Appearances. Cask X.—A woman of 40—severe A soft tubercular mass the size of shooting pain in the occiput—at first a hazel nut in the posterior lobe of alleviated towards evening—after- both hemispheres;—left lobe of the wards unremitted. Constant sick- cerebellum almost destroyed by the ness, and afterwards vomiting of softening of a similar tumour occupy- every thing taken. Death from gra- ing its interior; substance of the cere- dual exhaustion in four months. bellum around it indurated. Three ounces of fluid in the ventricles. Dr. Chalmers, Med. and Phy. Jour. July, 1826. It is unnecessary to multiply cases of this class, which pre- sent little variety in the phenomena. In a case by Willis, there was a tumour three inches broad adhering to the mem- branes at the side of the third sinus; and in one by Saviard there was, under the junction of the lambdoidal and sagittal sutures at the broadest part of the falx, a small triangular njece of bone with very sharp angles. Where these angles came in contact with the dura mater, it was livid and discharged a lit- tle pus. In a lady mentioned by Borellus there was, near the torcular, a hard rough irregular mass of a stony consis- tence, with many sharp processes and angles ; and in a case by Schenkius there was a stony tumour like a mulberry in the brain of a man who had suffered from long continued and in- tense headach, which left him no interval of ease day or night. See also the cases described under the head of tubercular dis- eases of the brain, particularly Cases LXXX. and LXXXVI. (pages 187-193.) which exhibit examples of organic diseases, with remarkable remissions of the pain. SECTION II. Second Class.—Headach, affections of the senses, speech, or intellect. Symptoms. Morbid Appearartces. Case XI.—A man, aged 42—after At the anterior part of the right exposure to the sun by walking in a hemisphere, a scirrhous mass the procession without his hat, was size of a nut, surrounded by exten- seized with headach, which became sive ramollissement of the cerebral intermittqpt, and was treated by substance---thalami sound---optic bark. After six weeks it ceased, but nerves shrivelled. left amaurosis. Then followed fever Cruvielhier Nov. Bib. De Med. Nov. and death. 1825. CASES OF ORGANIC DISEASES ON THE BRAIN. 449 Symptoms. Case XII.—A man, aged 47— headach and weight in the head, increased by stooping. Began in May, 1816, and increased gradual- ly notwithstanding copious evacua- tions. In August his sight began to diminish, with giddiness; in Septem- ber, could only see objects in a very strong light; in- December, perfect blindness—pain still constant and severe. In the middle of January stupor and forgetfulness, and died comotose on the 31st. Morbid Appearances. A tumour, the size of a large egg, attached to the tentorium in such a manner, that part of it lay above it and part below it, the falx likewise entering into its substance above. Internally it was firm, and resembled the structure of the kidney—four ounces of fluid in the ventricles. Author's Notes. Case XIII.—An officer who had seen much service—severe headach which subsided, and left a feeling of tightness across the forehead. After six or eight months, blindness of the right eye, then blindness of the left. Under the operation of an emetic, the sight of the left eye was recovered for an hour—afterwards perfect blindness and pupils insen- sible, but no other complaint, ex- cept disordered stomach, and fre- quent inclination to vomit. Death from coma after two years. Four ounces of fluid in the ventri- cles; a tumour, the size of a hen's egg, containing a thick purulent fluid, under the anterior part of the brain, and interposed betwixt the optic nerves, which were much se- parated by it from each other. Be- low it was attached to the pituitary gland, which was very soft, and en- larged to five or six times its natural size. Med. Trans, vol. v. Dr. Powel. Case XIV.—A man, aged 30—ex- cruciating headach, which com- menced after hard working in a hay field—chiefly referred to the fore- head, from which it extended over the left ear, but sometimes affected the right side of the head also, and occasionally the neck—most severe in the night. After six or seven weeks, blindness. At the end of two months an apoplectic attack, and death in two days. A tumour, the size of a large wal- nut, projected from the lower part of the anterior lobe of the left hemis- phere. Internally it resembled an absorbent gland. The greater part of the medullar}- substance of the left hemisphere was reduced to a soft pulpy state, and was of alight brown colour. Med. Trans, vol. v. Dr. Powel. In the other cases of this class the symptoms are nearly similar-fixed pain in the head and gradual loss of sight-the intellect being frequently affected in the advanced stages, and frequently the speech impaired. A case has been already described, in which there was blindness of one eye and loss of peech, in connexion with a cyst containing albuminous matter in the posterior part of the left hemisphere-(Sce Case 450 SUPPLEMENT TO PART III. LXXXVII. page 193.) In a case by Platerus, fatal by gradu- al wasting, there was a tumour larger than an egg, compress- in0- the origin of the optic nerves. In one by Drelincurtius there was a steatomatous tumour the size of a fist between the brain and the cerebellum. In this case there were both blindness and deafness, and it was fatal suddenly by an apo- plectic attack. In another by the same writer the pineal gland was enlarged to the size of an egg, and was of an earthy or stony structure. In a case by Bouillaud, with impaired sight and speech,'and loss of the memory of names, there was a tumour the size of a large nut in the anterior part of the left hemisphere. SECTION III. Third Class.—Headach—affections of the senses and convulsions. Symptoms. Case XV.—A girl, aged 11—long liable to headach, with weakness of sight, and a peculiar tenderness of the integuments of the head. In autumn 1814, she received an injury on the forehead from a fall, and from that time suffered much from headach, with frequent epistaxis. In the end of December, the headach increased, with fever, intolerance of light and sound—squinting and convulsive pa- roxysms, which for some time, recur- red every half hour. In March, 1815, she improved remarkably, and for nearly a year continued better in re- gard to the head symptoms, but af- fected with scrofulous sores on the neck and the leg. In. May, 1816, headach increased, with impatience of light and sound—squinting, gra- dual failure of sight, at last blindness in July. She died in October, her intellect having continued unimpair- ed; remarkable acuteness of hearing, and intolerance of sound continued to the last. Morbid Appearances. A tumour the size of a walnut rested on the cella Turcica, and com- pressed the junction of the optic nerves. It was composed of a me- dullary substance of a yellowish co- lour, and was covered by a thin and delicate membrane. Communicated by Dr. Hay. CASES OF ORGANIC DISEASES OF THE BRAIN. 451 Symptoms. Morbid Appearances. Case XVI.—A young man of 15— Four ounces of fluid in the ven- deep seated pain in the head, and tricles; on the left side of the pons after six months inarticulate speech. Varolii, a hard tumour the size of Three attacks of convulsion, each a bean; surrounding substance soft- of ten or fifteen minutes' duration; ened, approaching to suppuration. the last left palsy of the right side, Coindet sur tIJydrenceph. p. 98. which disappeared next day. Died comatose in another month, having had repeated convulsive attacks, intense headach, impatience of light, afterwards dilatation of the pupils, deafness, palsy of the eyelids, very difficult articulation, and some deli- rium. Case XVII.—A servant girl long Throughout the substance of both subject to headach', which, in her hemispheres, and in the corpora 19th year, became very severe, and striata, there were numerous tuber- occurred periodically, generally cles the size of peas. They were once in four weeks, and sometimes externally hard, and internally con- oftener. In her 21st year, the head- tained a small cavity full of a thick ach became more violent and per- greenish fluid. Twenty-one of them manent, with frequent vomiting, and were collected—substance of the occasional fits of insensibility. She brain healthy—corpora striata con- had then attacks of double vision, siderably softened. and afterwards convulsions, which Prof. Nasse, ut supra. returned at first once in five or six days, and afterwards every second or third clay. About three months after the commencement of the con- vulsions, she was one morning found dead in bed. Case XVIII—A woman, aged 19 Embedded in the substance of the —Headach, vertigo, suffusion of right hemisphere, there was an hy- the eyes; paroxysms, in which she datid, three inches long, and two fell down insensible, without con- broad, and very vascular. Brain in vulsion. They attacked her once in 0ther respects "healthy. three weeks, and at each time there Yelloly, Med. Clur. Trans, vol. ii. were two paroxysms at the distance of twelve hours; after eight or nine months, these attacks increased in severity. She had then loss of hear- ing, sight, and smell, and her speech and deglutition were much impaired. Soon after this died apoplectic. 452 SUPPLEMENT TO PART III. Symptoms. Case XIX.—A man, aged 24,— severe headach—watchfulness and imbecility of the head—blindness of the left eye, and after a month of the right. Convulsive paroxysms which continued to recur for six months; they then ceased, and he died of pectoral complaints. Case'XX.—A ehild of [4 years— unable to walk—articulation very imperfect—intelligence very defi- cient—deglutition very difficult, li- quids swallowed often returning by the mouth and nose—difficult respi- ration and frequent convulsions— but was full in flesh—had been in this state about a year—died in six months more. Case XXI.—A woman, aged 23— After suppressed menstruation, vio- lent headach, impaired vision and af- ter some time blindness. Repeated convulsive attacks; after one of which she lost her speech for two days. In- tellect entire. Died comatose after four months. Case XXII.—A lady, aged 40, of a scrofulous habit—gradual failure of memory, sight and hearing; inarticu- late speech; epileptic paroxysms, at first once in the fortnight, afterwards more frequent—her gait feeble and tottering—died in six months. A year before her death, she had been much stunned by a fall down a stair. Morbid Appearances. Extensive disease of the lungs: much effusion in the brain; in the substance of the left hemisphere, a tumour larger than an egg, weighing fourteen drams; it was covered by a fine sac, and internally was white, firm and uniform, resembling coagu- lated albumen, but harder. Felix Platerus, Liber I. 108. Corpora olivaria, cms cerebelli, and tubercula mammillaria in a state of cartilaginous hardness; other parts sound. Author's Notes. On the surface of the right hemis- phere there were three hardened spots, each an inch in diameter. They were the surfaces of tubercu- lar masses, which extended into the medullary substance of the brain. There was a similar tubercle in the substance of the hemisphere, and one smaller in the surface of the left hemisphere. Slight effusion in the ventricles. Powel, Med. Trans. V. A tumour, the size of a small orange, lay oh the pai's petrosa of the left temporal bone, inclining to the op- posite side, and producing great de- pression in the substance of the brain; the seventh pair of nerves, and the branches of the fifth pair were com- pressed and stretched by the tu- mour. Internally it consisted of a soft uniform substance resembling the cineritious matter of the brain. Communicated by Dr. Hay. CASES OF ORGANIC DISEASES OF THE BRAIN. 453 Symptoms. Case XXIII.—A man, aged 2(5— Severe headach; most distressing when lying on the left side; occur- ring in paroxysms with giddiness. After several months pain increased, with impaired vision and dilated pu- pil. Paroxysms of giddiness, with blindness; loss of speech, stiffness of the limbs during the paroxysms; then double vision; violent pain in the neck, with convulsive paroxysms affecting the muscles of the neck, and drawing the head violently back- wards. Two months after this he had numbness and spasmodic mo- tions of the superior extremities. After seven or eight months di«d sud- denly inafitjresembling epilepsy. Morbid Appearances. A hard tumour two inches long, and an inch and a half broad was firmly attached to the tentorium, and embedded^in the posterior lobe of the left hemisphere. It contained an ounce of greenish pus, and the cere- bral substance near it was softened. Where the tumour pressed against the occipital bone, the dura mater was obliterated, and the bone rough. Two ounces of fluid in the ventri- cles. Clerk, Edin. Jour. VI. p. 275. Case XXIV.—A man aged 35—se- vere headach, and sense of weight in the head for two years; copious epistaxis;"loss"of the sense of smell; then frequent epileptic paroxysms for two years—died suddenly. Cerebral substance on the anterior Eart of the right hemisphere was ard and callous, and adhered inti- timately to the dura mater; on the left side some extravasated blood. Morgagni, Epis. 9. Case XXV.—A man, (age not mentioned)—severe headach, fol- lowed by amaurosis and epileptic paroxysms, which occurred almost daily. He died in an apoplectic at- tack. On the inner surface of the left pa- rietal bone, there was an osseous spongy tumour, three inches broad, and more than an inch in thickness. Wepfer. SECTION IV. Fourth Class.—Convulsions, without affections of the senses.—Intellect sometimes impaired. r.„ XXVI —A man, aged 60— An hydatid the size of a pigeon's Epileptic for six years, with loss of egg, in the posterior part of the right P J™ n£d suddenly. hemisphere. It contained a yellowish memory. Died suddenly. fluid, which was partly gelatinous. The substance of the brain under it was hardened. Lancisius de Sub. Mori. cap. xi. 58 454 SUPPLEMENT TO PART III. Symptoms. Case XXVU.—A boy, aged 16 months, formerly healthy, was seized with an attack of convulsion. It af- fected chiefly his right side, which was very strongly convulsed. He had a second attack on the evening of the same day, after which he had fever, blindness, andloss of the pow- er of deglutition. In this state he con- tinued ten days, when he had another fit, and after this he gradually reco- vered his sight and deglutition. From this time there was a degree of paralysis of the right side, but in other respects he enjoyed good health for four years. He then had epileptic paroxysms, which at first occurred once in two months, but gradually increased in frequency. After a much longer interval than usual, a few weeks before his death the fits returned after a fright, re- curred with great frequency, and were fatal. He was then twelve years of age: his right side had con- tinued weak: and at the time of liis death the right lower extremity was three inches shorter than the other —his intellect had been weak, so that he never could be taught to read. Morbid Appearances. On the surface of the brain, under the left parietal bone, there was a tumour the size of an egg, situated between the pia mater and the arach- noid; internally it was of a white, and somewhat gelatinous appearance, but very firm, and when cut into, some serous fluid was discharged from it; no effusion. Communicated by Dr. Beilby. Case XXVIII.—A man, aged 40, the guard of a coach, was thrown from his seat behind the coach, and received an injury of his head, by which he was confined for several weeks. After his recovery he be- came epileptic. The fits generally occurred once in five or six weeks. After two years he fell from his seat behind the coach in one of the fits, and received various injuries, of which he died in a few days. There was thickening of the dura mater in several places. Attached to the inner surface of the thickened portions, tliere were several small nodules of bone, the size of peas, and very irregular on the surface. Communicated by Dr. Hunter. Case XXIX.—A child aged 20 months—No symptom remarked but a constant motion of the head from right to left—was pale but without fever, and did not seem to suffer. Died emaciated. In right lobe of the cerebellum—a round firm cyst, the size of a hazel nut containing numerous small hard concretions like pieces of bone. Andral. CASES OF ORGANIC DISEASES OF THE BRAIN. 455 Morbid Appearances. The tumour was generated in the substance of the dura mater. It pro- jected inwards into a hollow on the left hemisphere, and outwards through an opening in the bone which measured two inches by one and a half. The dura mater near it was remarkably vascular. Marigues. Mem~ de Chir. p. 26. Symptoms. Case XXX.—A woman aged 50 —Epileptic for thirty years; had cough which excited acute pain un- der the upper part of the occipital bone. In one of the epileptic fits she received a violent blow on this spot, followed by constant pain, and after six weeks, a pulsatory tumour appeared on the spot, which could be pressed back into the cavity of the cranium, and this produced co- ma. After several months, she had palsy of the right arm, and both lower extremities, and soon after died. Case XXXI.—A woman of 43— Four ounces of fluid in the ven- Headach; spasmodic affections of the tricles. A tubercle the size of a nut limbs. After seven months was con- in the left lobe of the cerebellum; fined to bed—violent paroxysms of surrounding substance much soft- headach, with loss of memory, and cned. frequent convulsive attacks, which Rochoux sur PApop. at last occurred several times a day. Died suddenly in one of them, six or seven weeks after she was con- fined to bed. It is unnecessary to detail particularly the cases of this class. They present the usual symptoms of the epileptic paroxysms occurring at various intervals, and in various degrees of se- verity; sometimes accompanied by violent attacks of head- ach, and sometimes with little uneasiness in the head. They are sometimes fatal suddenly in one of the fits, sometimes by coma. A variety of morbid appearances have been observed in such cases. Portal observed a remarkable induration of the pons Varolii; and Sandifort found three tubercles in the dura mater near the sagittal suture, on the right side, and in the anterior part of the right hemisphere, a sebace- ous tumour the size of a walnut. In a case by Lieutaud, there were seven sarcomatous tumours near the longitudi- nal sinus; and in another, a glandular tumour the size of a bean, in the substance of the right corpus striatum. In a voung man, mentioned by M. Poupart, in whom the fits occurred once a week, there was a thick white substance, firmer than jelly, under the dura mater. In a man men- tioned by Lamotte, who died of an abscess of the lungs, af- ter having been many years epileptic, several sharp bony spiculae were found between the dura mater and the pia 456 SUPPLEMENT TO PART III. mater; their points being directed against the pia mater. Several cases of the same kind are referred to by Van Swie- ten, in one of which there was an irregular piece of bone in the substance of the cerebellum, an inch long, and half an inch broad. In a case by Dr. Anderson of Leith, in which epilepsy came on after a severe injury on the back of the head, the posterior part of the brain was found inflamed, and much hardened, with thickening of the membranes. A modification of epilepsy is met with, in which the con- vulsion is confined to one side of the body. In a case of this kind by Dr. Anderson, a portion of the brain on the opposite side was much indurated, with adhesion and thickening of the membranes. The same peculiarity in the symptoms occurred in Dr. Beilby's case mentioned in this section. In a man mentioned by Lieutaud, the course of ] symptoms was somewhat different from those epileptic af- * fections. He had violent headach for three months, then k violent convulsions, which were rapidly fatal. The longi- j tudinal sinus, externally and internally, was covered with j innumerable smaller glandular grains, and similar bodies J were found on the choroid plexus. In the fourth ventricle there appeared a tumour the size of an egg, formed by a congeries of innumerable glandular bodies, verging to sup- puration. Nearly the whole of cerebellum had the same ap- j pearance. | SECTION V. Fifth Class.—Symptoms in the head with paralysis. § I.—Hemiplegia. Symptoms. Morbid Appearances. Case XXXII.—A woman of 77— A hard yellow cancerous mass, violent convulsions of the left arm, larger than a duck's egg, and com- which returned every two or three posed of many lobes in the substance daysfor ten weeks, with weakness of of the right hemisphere. the arm—then weakness of the leg, Boston, {Ramollissement de Cer- and gradually complete hemiplegia, veau.) the convulsion then ceasing—speech then lost, but mind entire—death after eleven months without any other symptom. CASES OF ORGANIC DISEASES OF THE BRAIN. 457 Symptoms. Casx XXXHI.—Aboy, aged 11— sudden attack of dimness of sight amounting to blindness. It went off in a few minutes, but from that time his sight was gradually impaired, and after a year was nearly lost. He then had an affection resembling chorea; and after a short time, suffered an attack in which he lay speechless for three days. This was followed by hemiplegia of the right side. He complained much of his head, which appeared to his friends to enlarge; and he sometimes lost his speech for two or three days. His intellect was not affected, but at times was ex- tremely acute. He died after coma of five weeks' continuance, about a year after the attack of hemiplegia, and two years after the commence- ment of the disease. Case XXXIV.—A man of 63— after a blow on the head, headach and sense of weight in the head, at first occurring in paroxysms, then more permanent, with slight weakness of the right side and transient loss of recollection. Symptoms gradually increased to perfect hemiplegia of the right side—loss of speech— twisting of the mouth to the left, and great failure of intellect. Died comatose after more than two years. The coma continued a week. Case XXXV.—A boy of 13— headach—hemiplegia of the left side for five or six weeks before death- loss of speech and memory—rigidity of the paralysed limbs—occasional pain in the affected leg, and tremu- lous motions of both arms—tetanic symptoms. Morbid Appearances. On the surface of the left hemis- phere, the membranes adhered firm- ly to the surface of the brain in the middle lobe—on raising them at this place, fluid escaped in great quan- tity, which was found to have been discharged from the cyst of an im- mense hydatid contained within the left lateral ventricle, and which had nearly advanced to the circumfe- rence of the brain. It contained about sixteen ounces of limpid fluid, and besides this, there were several ounces in the proper cavity of the ventricle. Communicated by Mr. Headington of London. A reddish-brown and firm tumour the size of an egg, on the outer and anterior part of the left hemisphere: it was full of blood, which seemed to be contained in it in some places as it is in the spleen; in others it was in small clots a line or more in dia- meter, and very firm. The tumour adhered slightly to the dura mater and the arachnoid, which was red and thickened where it covered the tumour. Below it was embedded in the substance of the hemisphere, and the cerebral matter was soften- ed. One ounce of fluid in the ven- tricles. Rochoux. A tubercle the size of a large egg, and five or six smaller ones in the substance of the right hemisphere; four in the left the size of chesnuts— several of them suppurated—pus be- twixt the arachnoid and pia mater, and turbid fluid in the ventricles. Bouillaud. 458 SUPPLEMENT TO PART III. Symptoms. Morbid Appearances. Case XXXVI.—A man, aged 36— A tumour, the size of a hazel nut occasional attacks of severe headach lying on the left side of the tuber an- shooting from behind forwards. After nulare, and sunk into it. Itextcnd- a few months double vision—then ed to the left corpus pyramidale, gradually palsy of the right side, compressing it and the abductor with distortion of the mouth and in- nerve, and was closely attached to articulate speech; the left eve drawn the basilar artery, which contained towards the nose—pulse natural, at this place a small coagulum, and About two months from the com- its coats were very soft. The tu- mencement of the paralysis, he be- mour was in a state of imperfect came convulsed, and died in twenty- suppuration. four hours. Yelloly, Med. Chir. Trans. I. 181. The cases of this class present little variety in the symp- toms. They are generally, headach with or without affec- tions of the sight, and after some time weakness of one side, which gradually increases to perfect paralysis. In a case by Bonetus, and in another exactly similar by Blancardus, there was a tumour threeincheslongattached tothesize of the third sinus. A gentleman, mentioned by Mr. Gooch, along with a variety of nervous symptoms, had an excruciating pain of one arm, beginning at the finger ends, and gradually ascend- ing as high as the insertion of the deltoid. The arm at last became paralytic, and soon after he died of convulsion. Two small encysted tumours were found in the surface of the brain on the opposite side from the affected arm. In a case by Bouillaud, with partial hemiplegia of the right side of long standing, with much derangement of speech and weak- ness of mind, there was a tumour the size of an egg in the anterior lobe of the left hemisphere, and another smaller in the middle lobe. They were internally cellular, and con- tained blood mixed with a filamentous substance, and a mat- ter resembling concrete pus. § II.—Paraplegia. Symptoms. Morbid Appearances. Case XXXVII.—A man of 48— Left lobe of the cerebellum was acute headach for a year followed by almost entirely schirrhous, of a pale- paraplegia. Five months after died flesh colour, and seemed to be corn- suddenly, posed of numerous small corpuscles closely compacted, without any in- terstices, or any appearance of ves- sels. Morgagni, Ep. 62. CASES OP ORGANIC DISEASES OF THE BRAIN. 459 Symptoms. Case XXXVIII.—A man of 35— fixed pain in the occiput extending down the neck—occasional vertigo and sickness. After five months,he- miplegia of the left side and impair- ed vision. Hemiplegia diminished gradually, and after five or six months more, he became liable to fits of stupor, which were preceded by violent pain and vertigo, and oc- curred occasionally twenty times in a day—blindness of the right eye— failure of memory—then paraplegia; and a fortnight before his death palsy of the upper extremities also.—Du- ration of the complaint was a year and eight months. Morbid Appearances. On the surface of the pons Va- rolii, there were two triangular fleshy tumours nearly united by their api- ces. The base of one extended into the right crus cerebri, that of the other into the medulla oblongata. The disease penetrated into the substance of the pons. There was much effusion under the arachnoid. Edin. Jour. XI. 470. Case XXXIX.—A man, aged 63 —general and complete paralysis of the whole body, which came on gradually and insensibly without any evident cause—speech indistinct— mind entire to the last. Died of grangrene of the nates. A tumour the size of a hen's egg in the medullary substance of the left hemisphere, betwixt the fissure of Sylvius and the part which rests upon the tentorium. It was contain- ed in a cyst, and was internally of a brownish colour and lardy consis- Bul. Fac. Med. May, 1816. I have already alluded to the uncertainty which attend cases of this class, from the circumstance of there having been in general no examination of the spinal cord; and perhaps it may still be considered as a point not absolutely ascertained, whether disease in the brain produce paraplegia without any affection of the cord. If this does take place, it will proba- bly be in those cases in which the disease is about the pons or medulla oblongata; though in these cases one should ra- ther expect universal paralysis, such as occurred in Cases XXXVIII. and XXXIX. of this Supplement. From the ob- servations recorded under the pathology of the spinal cord, it will appear that disease may frequently exist both m the brain and in the cord at the same time, and that this particu- larly is true of tubercles. In a case related by Dr. Hawkins in the Medical and Physical Journal for 1826, there were numerous scrofulous tubercles, both in the brain and cerebel- lum in a man of 23; the symptoms had been fits resembling epi- lepsy with dysuria,partial paraplegia,and impaired speech and vision He died after four months, having been comatose for three or four days before death. Had the spinal cord been ex* 460 SUPPLEMENT TO PART III. amined in this case, it is very probable that tubercular disease would have been met with in it also. The same observation applies to a case by Bouillaud, in which there was paraplegia with loss of speech and intellect, in connexion with a tuber- cular mass, the size of a turkey's egg in the anterior part of the right hemisphere. A girl, aged 14, mentioned by Lal- lemand, had hemiplegia of the right side, of which she reco- vered ; four months after she had paraplegia with loss of feeling, which extended over the abdomen and the thorax; she died in sixteen days. There was remarkable induration of a small part of the left lobe of the brain, on the outside of the ventricle j but in the vertebral canal, there was extensive extravasation of blood, with ramollissement of the cord at the seventh cervical vertebra. SECTION VI. Sixth Class.—Prominent symptoms in the digestive organs. Symptoms. Case XL.—A medical man, in the meridian of life, had been for a year liable to attacks of dyspepsia, with headach. In October, 1815, he had severe headach with fever relieved by blood-letting: then complete want of digestion, headach, general ema- ciation, and frequent vomiting, which occurred chiefly in the morning. He had various uneasy feelings, which he referred to his liver, and his com- plaints were ascribed to this source by the most eminent practitioners whom he consulted. In August, 1816, he had severe headach, and nothing agreed with his stomach; almost every thing being vomited. After some time, the pain was re- lieved, but the morning sickness and vomiting continued, with in- creasing emaciation, torpid bowels., frequent eructations, and hiccup. In the end of September had twice a slight convulsion. Headach then periodical—mind entire, but con- versation induced headach, and sometimes convulsion. October, 9, died suddenly in convulsion. Morbid Appearances. Four ounces of fluid in the ven- tricles. On the inferior part of the left lobe of the cerebellum, there was an encysted tumour, the size of a French walnut, besides a vesicular portion connected with it containing some yellow serum. The tumour was invested both by the dura mater and pia mater and was attached by a small pedicle to the substance of the ce- rebellum, where it had formed a de- pression in which it was embedded. On the corresponding part of the opposite lobe there was a small florid tumour the size of a large pea. The abdominal viscera were sound. Med. Repos. vol. vii. cases of organic diseases of the brain. 461 Symptoms. Morbid Appearances. CaseXLI.—An officer, aged 27— The dura mater covering the ce- constant nausea and frequent vomit- rebellum at its posterior and infe- ing—slight thickening of the peri- rior part was thickened and cartila- cranium—headach and general in- ginous, and the diseased state had disposition. After a considerable extended considerably into the sub- time, numbness of the right side, stance of the cerebellum, where it Five weeks after tliis, he died sud* Liv in contact with it. Other parts denly in the night. of the cerebellum softened, mem- branes of the spinal cord hard and thickened. Thoracic and abdomi- nal viscera sound. Med. Repos. vol. viii. Many other cases are on record, in which the only morbid appearances were in the head, though some of the most pro- minent symptoms had been in the stomach. Some of these resemble what has been called sick headach, while others are chiefly distinguished by remarkable disturbance of the digestive functions. There is generally more or less headach, with va- rious uneasy feelings in the head; but these symptoms are sometimes not urgent, so that many of the cases have, through a great part of their progress, been referred to the digestive organs, the symptoms in the head being considered as symp- tomatic. A boy, aged 14, mentioned by Mangetus, had los3 of appetite, obtuse headach, debility and emaciation ; then vomiting, with more acute headach, and he died after various intermissions. Three tumours were found in the brain, one in the situation of the corpora quadrigemina, and two others the size of walnuts in the substance of the brain. A young man mentioned in the Medical Observations and Inquiries, vol. vi. had various complaints in the head and bowels, which were ascribed to worms. After some time he had attacks of stupor and forgetfulness, and died delirious. The only mor- bid appearance was ossification of no great extent in the du- ra mater, with appearances of inflammation m the adjoining membranes. Similar ossification in the falx was found by Dr. Lettsom, as the only morbid appearance in a gentleman who had been lon^ aiFccted with a train of obscure complaints, the most urgent of which were obtuse headach, with frequent vomiting. (Mem. Med. Soc. of London, vol. iii.) On the other hand, it is to be kept in mind that similar ossifications have been met with in cases in which there existed no symp- toms that could be ascribed to them. This part of the sub- ject, therefore, is involved in much obscurity. 59 462 supplement to TART III. SECTION VII. Seventh Class.—Vertigo and apoplectic symptoms. —slight and transient apoplectic attacks. Symptoms. Case XJ.II.—A man, aged 73— headach, with occasional attacks of giddiness, and loss of recollection. He did not generally fall down, but sometimes continued walking, without knowing whither he was going; at other times the attack re- sembled intoxication; his gait was feeble and tottering, and the attacks gradually increased in frequency and violence, though he generally recovered his recollection in a very short time: but at length, after six months, a more severe attack occur- red, from which he did not recover: he was now confined to bed with se- vere headach, giddiness, loss of me- mory, and incoherence; and about the 12th day had severe pain and partial palsy of the left leg and arm. He had then general convulsion, followed by perfect hemiplegia and coma, and died about the 23d day of his confinement. Case XLHI.—A man, aged 36— after a wound in the head, which healed readily, had constant headach for five years and a half; then fits of 6tupor, which came on at uncertain intervals, sometimes twice a week, sometimes once a fortnight. They generally lasted about an hour and a half, and he had warning of their ap- proach, so as to lay himself down. In the intervals all the functions were natural. After seven or eight months the paroxysms became more fre- quent, and he died suddenly in one of them. Morbid Appearances. Three ounces of fluid in the ven- tricles; cerebral substance very firm. In the posterior lobe of the right he- misphere, there was a firm tumour the size of a small pigeon's egg; in- ternally of a pale flesh colour, and granular texture. It was not en- closed in a capsule; but for a consi- derable part of its circumference, was covered by a texture resembling the fibrous bands of carcinoma. The tumour communicated with the ven- tricle so as to form part of the wall of the posterior and inferior cornua, and the margin of the pes hippocam- pi was attached to it. The pia ma- ter lining the ventricle at this place was very vascular. Communicated by Dr. Ifuntir. A scrofulous tumour, larger than a hen's egg, in the middle of the left hemisphere of the brain, extending in depth to nearly on a line with the corpus callosum. It seemed to be merely a part of the brain in an indurated state. A piece of bone, the size of the finger nail, was attach- ed to the leftside of the longitudinal sinus. The veins on the left he- misphere were more distended with blood than those on the right. Med. Chir. Trans. IV. 188. CASES OP ORGANIC DISEASES OF THE BRAIN. 463 Symptoms. Case XLIV.—A woman, aged 28 —severe headach, constant vertigo, nausea, occasional vomiting, fre- quent rigours, pain and deafness of the left ear, and the left eye some- what affected. After several months the headach increased, with occa- sional paroxysms of coma, and she died at last rather suddenly, having been for a day or two affected with extensive erysipelas of the head and face. Morbid Appearances, A remarkable tumour under the ase of the brain on the left side, resting on the petrous portion of the temporal bone. It consisted of three portions; the anterior was the size of an egg, of a pink colour, and com- Iiosed of a spongy vascular substance, ike the texture of the placenta, in- terspersed with small cysts, contain- ing a puriform fluid; the posterior portion was half the size of the for- mer, and of similar structure, but firmer; the middle portion was the size of a walnut of a white colour, and nearly cartilaginous structure. The petrous portion of the bone on which the tumour rested was absorb- ed to the depth of half an inch. Author's Notes. CaseXLV.—A lady, aged 64— attacks of headach; giddiness and imperfect vision, occurring at uncer- tain intervals: afterwards mania; at last, after five years, death with fe- ver and delirium. Two small aneurisms, each about five-eighths of an inch in diameter, formed by dilatation of the internal carotid arteries, by the side of the cella Turcica, and containing lami- nae of coagulated blood. Trans.ofaSoc. II. 193. Case XLVL—A woman, aged 65 Extravasation of blood and ramol- —palsy of the right leg of long stan- lissement. The anterior part of the ding; lancinating pains of the head, left hemisphere was very much hard- occurring at intervals; attacks of in- ened, and of a reddish colour. In sensibility; death from gradual coma the substance of the right hemis- after an apoplectic attack. phere there was an oval tumour of a reddish colour, partly hard and partly softened. Rostan. I have formerly described a very important case referrible to this class, connected with a remarkable tumour formed by a deposition of new matter betwixt the laminae of the dura mater.—(See Case VI. page 65,) and there are many others on record exhibiting some varieties of the symptoms. In some we find constant uneasiness, with vertigo; in others, transient apoplectic attacks, while the patient in the intervals enjoys tolerable health. In other cases again, there is a constant complaint of slight and habitual giddiness, commonly called weakness of the head, often accompanied by unsteadiness of the limbs. In a case of the first kind, by Zeder, he found nu- 464 SUPPLEMENT TO PART III. merous hydatids in the brain, one particularly, in the passage to the aqueduct of Silvius, and containing within it three smaller hydatids. The case which I have just referred to (Case VI.) affords a remarkable example of the other class of ' cases distinguished by transient apoplectic attacks; and I have quoted from Lancisius the case of a gentleman who had apoplectic attacks, connected with thickening of the mem- branes, and a polypous tumour under the frontal bone. A gentleman mentioned by Gooch, had been for several years liable to attacks in which there was sometimes a shaking of the head, and a kind of emprosthotonos; at other times he became vertiginous, and fell down, deprived of sense for a short time. He was never entirely free from headach, and brisk exercise excited giddiness, which went off immediately upon resting. He died suddenly in convulsion, and there were found several osseous points arising from the right pa- rietal and occipital bones, and irritating the dura mater, which was inflamed, and beginning to mortify.—(Gooch's Appendix p. 237.) To this class also belong the cases in which, connected with organic disease of the brain, there has occurred a grad- ual loss of the mental faculties, with little complaint of pain, or any urgent symptom. In a case of this kind, which ter- minated in perfect stupidity or lethargy, Platerus found a firm fleshy looking tumour the size of a moderate apple, above the corpus callosum. In a similar case, by Bouil- laud, there was a steatomatous encysted tumour in the right hemisphere. FINIS. m||Puv^c. - i'l 3&v \ '*/■■ 'I r M • ■_ -? 47 1 ■:> l *, 1 V < 18s i 7JK \ A. • ^ •-'-■■ ■ ■ - i 1 . ^.l^ypi S^"S§ »^ '■ <% i'u:« J - • *&\, . .& ^^i^dr" v V SMS **.' *•**#* >-^ 1 lyp/..."> *~,J ; <**£ 1 **▼** V V