* •**•■ >.vivV> v »^5u£'D0O0OCO0O0t>0lC>C jO'PC'D>£yD^& ij ii Surgeon General's Office 2s ll «sp * tjee/ton, fei* "ZiMfoiS ■-ICCC13 "? jGI'.--- ■ s JTOOQiC? *# fc MEDICAL CLINIC: BY G. ANDRAL, PROFESSOR OF THE FACTJITT OF MEDICINE OF PARIS, MEMBER OF THE HOTAL ACADEMY OF MEDICINE, ETC., ETC. VOL. III. DISEASES OF THE ENCEPHALON. MEDICAL CLINIC: DISEASES OF THE ENCEPHALON, WITH EXTRACTS FROM OLLIVIER'S WORK ON DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. / G. ^JNTDRAL, PROFESSOR TO THE FACULTY OF MEDICINE OF PARIS, MEMBER OF THE ROYAL ACADEMY OF MEDICINE, ETC., ETC. CONDENSED AND TRANSLATED, WITH OBSERVATIONS, BY D. SPILLAN, M.D., FELLOW OF THE KING AND ftUEEN'S COLLEGE OP PHYSICIANS IN IRELAND, MEMBER OF THE ASSOCIATION OF THE FELLOWS AND LICENTIATES OF THE COLLEGE OP PHYSICIANS, AND FORMERLY PHYSICIAN TO THE DUBLIN GENERAL DISPENSARY. t v.. ^fttlaflelphfa: ED. BARRINGTON & GEO. D. HASWELL. NEW YORK-J. & H. G. LANGLEY: CHARLESTON, S. C.-WM. H. BERRETT RICHMOND. VA. - SMITH, DRINKER, AND MORRIS. LOUISVILLE, KY. — JAMES MAXWELL, JR. 1843. WB HI /\S54c CONTENTS. FIRST BOOK. DISEASES OF THE ENCEPHALIC MEMBRANES. PAGE Section I. — Diseases of the Dura Mater......13 Section II. — Diseases of the Arachnoid and Pia Mater 16 Chap. I.—Cases of Diseases of the Arachnoid and Pia Mater covering the upper surface of the Brain . . 17 Chap. II. — Diseases of the Meninges of the lower surface of the Brain.........33 Chap. III.— Diseases of the Meninges covering the parietes of the Ventricles of the Brain......35 Chap. IV. — Cases wherein the entire of the Meninges were involved 45 Chap. V. — Diseases of the Membranes of the Spinal Cord . . 52 Recapitulation.— Chap. I. — Lesions detected in the Meninges by post- mortem examination. Art. 1. — Lesions of the Dura Mater .... Art. 2. — Lesions of the Arachnoid .... Art. 3. — Lesions of the Pia Mater..... Chap. II. — Disturbances of Function .... Art. 1. —Disturbances in the Functions of Relation Section I. Lesions of Sensibility .... Art. 2. — Lesions of Motion Art. 3. — Lesions of the intellect Chap. III. — Disturbances of the Functions of the tive Life .... Art. 1. — Lesions of the Functions of the Digest Art. 2. — Lesions of the Circulation Art. 3. — Lesions of Respiration Organs of Nutri ive Apparatus Supplement. — Spinal Meningitis . Symptoms of Meningitis SECOND BOOK DISEASES OP THE BRAIN. 61 65 67 71 72 72 79 86 90 91 93 95 9G 99 First Order. — Cerebral Congestions.......102 Recapttulation . . . . . . • • • . .110 Second Order.—Cerebral Hemorrhage......137 IV CONTENTS. PAGE Recapitulation.— Chap. I. Lesions of Motion ..... 155 Chap. II. Lesions of Sensibility .... 163 Chap. III. Lesions of the Intellect . . . . 168 Chap. IV. Lesions of the Functions of the Organs of Nutritive Life.....171 Supplement. — Spinal Congestions.......173 Third Order.—Softening of the Cerebral Hemispheres . . . 193 Chap. I. — Cases where no Symptom announced the softening . 195 Chap. II. — Cases where the Disturbance of Motion was the only symptom........ 196 Chap. III. — Cases where, with different Lesions of Motion, there existed a Lesion of Sensibility .... 209 Chap. IV. — Cases in which the Loss of Speech was the only Symptom, or one of the predominant Symptoms . 214 Chap. V. — Cases in which, with divers Disturbances of Motion and Sensation, there was Disorder of the Intellect . 215 Art. 1. — Softening of the Brain, with complete and sudden Loss of Consciousness . .....216 Art. 2. — Softening of the Brain, with Weakness or Perversion of the Intellect.......222 Recapitulation...........228 Fourth Order. — Hypertrophy of the Cerebral Hemispheres . . 248 Fifth Order. — Observations on Atrophy of the Cerebral Hemispheres . 257 Sixth Order. — Observations on Cancer of the Brain .... 263 THIRD BOOK. DISEASES OF THE CEREBELLUM. Section I. — Observations on Hemorrhage of the Cerebellum . . . 274 Section II. — Observations on softening of the Cerebellum . . . 275 DISEASES OF THE ENCEPHALON AND ITS MEMBRANES. FIRST BOOK. DISEASES OF THE ENCEPHALIC MEMBRANES. SECTION r. DISEASES OF THE DURA MATER. Case 1.— Fibrous vegetation on the inner surface of the dura mater, with considerable depression of the part of the brain corresponding to it—Hemiplegia—Intellect per feet—Headache of an old standing. A military man, sixty-one years old, entered the Hospital La Charite in the beginning of March, 1829. He appeared to have been of a good constitution, but when he presented himself he was very much emaciated ; his countenance was of a pale colour, some- what yellowish; one-half of the right eyelid was depressed before the globe of the eye, and it was incapable of being completely raised at the will of the patient; both extremities of the right side were deprived of the power of motion, and their sensibility was impaired ; the urine was passed involuntary; pulse remarkably slow. The patient stated that, after having experienced, for a long time, rheumatic pains in different parts of the body, he was seized, about the beginning of the year 1817, with a headache, seated principally towards the anterior part of the left parietal bone. This pain was at first intermittent; then became continued for an entire year; then, from the middle of 1819, it disappeared altogether. This headache, the only thing the patient complained of, was at times in- supportable. Nearly about the time it ceased, he thought the right upper extremity felt somewhat more insensible than the left, as did also the fingers of this side from time to time; they were cold, and 2 14 AXDRAL'S MEDICAL CLINIC. usually presented a violet appearance. He gradually became unable to grasp anything with the right hand. Subsequently, the right upper extremity became completely paralytic, at the same time that the left lower extremity lost the faculties of sensation and motion. For the first ten or twelve days after entering the hospital the state of the patient did not change; then the tongue became dry, and the pulse frequent; his intellects became disturbed ; diarrhoea came on ; a broad eschar formed on the sacrum, and the patient died in an adynamic state towards the end of March. Post-mortem. — Considerable emaciation. On raising the vault of the cranium, no appreciable lesion on the external surface of the dura mater. On making an incision, however, into it, this mem- brane was found to have contracted unusual adhesions to the subjacent parts. These adhesions were formed by cellular bands, which united the two layers of the arachnoid to each other. These bands circumscribed a spherical body of the size of a large nut, which sank deep into the cerebral substance with which it had notcontracted adhesion in any other part. It was separated from it by a cellulo- vascular layer, which appeared to be the tissue of the arachnoid and pia mater compressed by it. This body was attached by a narrow pedicle to the inner surface of the dura mater, the fibres of the latter membrane being dispersed over the pedicle of the tumour, and so confounded with its tissue, that to distinguish them was impossible. This tissue, which was of considerable hardness, and of a white ten- dinous appearance, consisted of fibres which were, as it were, wound up one upon another ; they seemed a prolongation of the fibres of the dura mater. Some infarction in the posterior part of the lungs ; two white spots on the pericardium. The mucous membrane of the stomach, towards the great cul-de-sac, presented some red points ; the end of the ileum and part of the colon presented a bright red colour. Remarks. — From the nature of the symptoms and progress of the disease, one would have expected that softening was the lesion to be found in the brain in this case. That permanent flexion of the limbs oftentimes, though not always, accompanying softening, was not however here observed at any period. The rheumatic pains preceding the pain of head, might have led one to consider the latter also as rheumatic. There is not a doubt but that pain of head simi- lar to that we have described in this case, has been many times taken as the effect of neuralgia and rheumatism. The pain of head was here the first symptom observed, and it coincided probably with the commencement of the disease of the dura mater, and continued as long as the inflammatory process, necessarvfor the formation of the adhesions described in the post-mortem, existed around the tumour, and ceased probably when the adhesions were changed into cellular tissue. The gradual manner in which the paralysis deve- loped itself was conformable to the nature of the disease; it was not preceded by any loss of consciousness, and the intelligence was never disturbed. No lesion explained the incontinence of urine. DISEASES OF THE ENCEPHALIC MEMBRANES. 15 A bright redness of the stomach, and a portion of the intestine, coincided in this case with the adynamic symptoms under which the patient sank.* Case 2.—Osteo-fibrous tumour, of the size of a pullet's egg, on the inner surface of the tentorium cerebelli, to which it closely adheres—Hemiplegia, with convulsive movements at intervals, on the side opposite that where the tumour was—Atrophy of the lobe of the cerebellum, corresponding to the tumour—Death by cerebral hemorrhage. A shoemaker, forty-seven years old addicted to spirituous liquors, fell on the occipital bone when drunk, about four years before en- tering the La Chariti. Immediately after the fall he experienced no uneasiness. Subsequently, however, he began to feel a dull pain towards the left part of the occipital bone, which continued for a considerable time without becoming severe. Giddiness occurred also from time to time, often followed by total loss of consciousness, which never continued, however, beyond a few minutes. At a later period new symptoms presented themselves; on a sudden the up- per extremity of the right side was attacked with a painful, and as it were tetanic shock. Five or six of these shocks rapidly followed this, and during the three or four days following, the right arm continued torpid and somewhat weaker than that of the opposite side. At first there were intervals of months between these attacks : they then became more frequent, reappearing every ten or twelve days, uniformly limited to the right arm, at the same time pa- ralysis of this limb, at first transient, became permanent, and more and more complete. Insensibly also the right lower extremity lost the power of motion; it never however exhibited any convulsive movement. Before entering the hospital he was attacked with gid- diness, which, becoming more severe, determined him on applying for admission. His state then was as follows:— The face and eyes injected; some difficulty in articulating his words; answers slow, but correct; recollection clear; diplopia from time to time ; commencing deafness. The patient complains of a dull pain towards the back part of the head, on the right side as well as on the left. The two extremities of the right side cannot be moved at the will of the patient; they exhibit however a cer- tain rio-idity, and yesterday again the arm underwent five or six shocksf which caused the patient to surfer considerably. Pulse very- hard, but not frequent. The pulsation of the heart strong. The muscular system even still remarkably well developed. Just when I had drawn up these details, and we were going to bleed the patient, he was seized with all the symptoms of apoplexy, and died the following day. , . Post-mortem. —In the place ordinarily occupied by the left part of the tentorium cerebelli, there was found a large tumour which compressed the posterior lobe of the cerebral hemisphere of this * For some very interesting cases illustrating the effects of pressure from tu- mours, see Dr. Bright's Reports of Medical Cases, vol. n. part 1, p. 342, &c. 16 ANDRAL'S MEDICAL CLINIC. side, and also the cerebellum. The structure of the cerebral hemi- phere not changed, the tumour being principally developed on the side of the cerebellum, the entire left lobe of which had under- gone a most remarkable change, it being very much diminished in volume, and its substance having acquired extraordinary hardness. Neither the cerebrum nor cerebellum were continuous with the tumour. Interposed between them, and evidently produced at the expense of the dura mater, whose place it occupied, this tumour very much resembled that described in the preceding case, except that it contained in some parts a little calcareous deposit. In the right hemisphere of the cerebrum was found an enormous sangui- neous effusion, which, occupying the corpus striatum and optic thalamus, had made its way into the two lateral ventricles through the lacerated septum. The parietes of the heart were hypertro- phied. Remarks. — In this, as in the preceding case, the cerebrum was not all affected ; but one of the lobes of the cerebellum, being com- pressed by it, underwent considerably atrophy. Still none of those functional disturbances, which, according to authors, are connected with lesions of the cerebellum, were here remarked. The symp- toms were just the same as if the tumour were seated in the cere- brum. The development of the osteo-fibrous tumour of the dura mater, seemed to be owing originally to the fall which the patient had suffered several years previously. SECTION II. DISEASES OP THE ARACHNOID AND PIA MATER. There are few diseases whose symptoms present so many varie- ties and so many individual differences as acute inflammation of the meninges. Are there well marked signs, by the aid of which we may readily distinguish during life inflammation of the meninges lining the upper surface of the brain from that connected with the lower surface of this organ 1 Are there any special functional disturbances appertaining to inflammation of the membrane lining the parietes of the ventricles ? By what signs can we recognise in- flammation of the membranes lining the spinal cords ? Whatever be its seat, can acute meningitis be distinguished by its symptoms, either from the other acute affections of the encephalon, in which this organ is found materially changed, or from those very frequent cases in which irritation of the brain or its coverings, merely sym- pathetic of irritation of some other organ, leaves no trace of its ex- istence in the dead body ? In a word, in the dead body itself, what are the anatomical characters by whose aid we shall be enabled to affirm that there really was acute meningitis in the cases where during life, symptoms existed which seemed to belong to it? Such are the questions as yet undetermined in science, in the solution of which we think the following cases will assist. DISEASES OF THE ENCEPHALIC MEMBRANES. 17 CHAPTER I. CASES OP DISEASES OF THE ARACHNOID AND PIA MATER COVERING THE UPPER SURFACE OF THE BRAIN. Case 3. — Effusion of blood between the Arachnoid and Dura Mater. A coachman, seventy-three years of age, of a strong constitution, had fallen from his seat nine years previously, and received a deep cut in the left temporal region, for which he was trepanned at the La CharitL He had not lost his consciousness from the fall, and after it he continued to enjoy perfect health. Towards the 20th March, 1822, he felt, without any known cause, both in the lower extremity and in the arm of the right side, a numbness, with difficulty in moving these limbs, pains also in the elbow and heel; at the same time vertigo, ringing of the ears, head- ache, and somnolence. The following days there was gradual aug- mentation of these symptoms, and at length he became unable to follow his usual calling. Three days before entering the hospital the motions of the left lower extremity began to be difficult. When he entered the hospital on the 6th of April, 1822, he pre- sented the following state : — obstinate constipation, tongue natural.. The two extremities of the right side could still perform some motions, but very feebly ; the left lower extremity was somewhat less weak than the right; pulse full and strong. Twenty leeches to the neck, friction on the limbs with camphorated spirits. On the 8th, a diminution of the vertigo, headache, and somnolence ; had two evacuations in twenty-four hours. Eighteen leeches to the neck, sinapisms to the legs. On the night of this day delirium set in. The following morning less pain of head, but the paralysis more marked. The three following days a gradual increase of the latter. On the 13th the countenance very much injected, drowsi- ness, pain on moving the right arm; hemiplegia of the left side incomplete, whilst that of the right side is complete ; tongue red and dry, feeces and urine passed unconsciously ; pulse strong and quick; skin hot and dry (enemata and leeches to the neck, and blisters to the legs with diluent drinks). On the 14th, respiration stertorous; total loss of consciousness; coma. He died in the evening. , , Post-mortem. — The arachnoid thickened and red, was detached from the dura mater of each side by an effusion of blood, partly fluid and partly coagulated, which had completely separated the serous membrane from above downwards, from the part adjoining the great falx of the dura mater to the temporo-panetal suture, and from before backwards, from the coronal fossa to the posterior end of the parietal. The detachment and effusion were more considera- ble on the left. The depression of the hemispheres was nearly an inch on the left, only half an inch on the right. Beneath the effusion 2* IS ANDRAL'S MEDICAL CLINIC. the cerebral substance was very firm, and presented very few bloody points, but the sinuses contained a considerable quantity. Remarks. — We have here a rare case of pathological anatomy. It is not easy to conceive how a thin fine membrane, such as the arachnoid is, can be separated from the dura mater by effused blood without being torn. The symptoms here were altogether in relation to the seat and nature of the lesion. The prevailing symptoms existed at first with respect to motion ; there was double paralysis, as there was double effusion. It was not till a later period the intellectual facul- ties became disturbed. The hemorrhage, slowly produced, acted at the same time by compressing and irritating the brain. Case 4.—Effusion of blood between the Arachnoid and Dura Mater—Gradual para- lysis of the right side with permanent flexion. A man, seventy years of age, of a lymphatico-sanguineous tem- perament and weakly constitution, felt, for the last two months, on the left side of the head, and particularly in the temporal fossa, a constant headache, which went on increasing up to the 4th of May. We could obtain no particular account with respect to the nature of this pain, and the symptoms accompanying it. We only know, that at the above mentioned period, the patient began to stammer, the tongue became embarrassed, the intellect seemed weakened, and in the morning the right side of the body was imperfectly paralysed. This hemiplegia made very slow progress on the following days. There was added to it continued fever with adynamic symptoms. When brought to the hospital on the 15th of May, he presented the following state :—Prostration, lying on his back, pupils equally moveable, countenance very flushed, features drawn to the right, lips dry, tongue red, dry, cleft, trembling, but no deviation to either side ; breath fetid, stools and urine passed involuntarily. Considerable heat of skin, with moisture ; pulse strong, full, and frequent. The extremities of the right side present a paralysis of motion, but not of sensation. To this is added, in the upper extremity, strong contrac- tion of the flexor muscles of the fore-arm on the arm; the patient seems to understand what is said to him, but he answers very indis- tinctly. Great drowsiness (two blisters to the right lower extremity, one to the thigh, one to the leg). On the 16th and 17th, gradual increase of the hemiplegia ; the rigidity of the upper extremity con- tinued up to the 20th, when there was observed stupor, stertor, total extinction of intellect (twenty-five leeches to the neck, two sinapisms to the feet). On the 21st the rigid contraction of the right arm ceased, total loss of motion and sensation on the right side, breath- ing stertorous, eyes dull, pupils equally moveable, pulse continually full and strong, skin hot and moist (sixteen leeches to the neck). Died at ten o'clock at night. Post-mortem.—The vessels uniting the bones to the dura mater appeared very much injected on the left side ; on dividing this mem- brane we found between it and the arachnoid, along the posterior, three-fourths of the lateral wall of the cranium, and from its base to DISEASES OF THE ENCEPHALIC MEMBRANES. 19 the falx of the dura mater, an effusion of blood partly liquid, partly coagulated, black, depressing the serous membrane for nearly an inch at the centre, gradually diminishing in thickness to the circumference. The two folds of the arachnoid were red and thickened. The cerebral substance of the two hemispheres were dotted with blood ; a little serum in the ventricles; heart very soft and flaccid; brownish colour of the gastric mucous membrane, towards the great curvature. Remains. — One of the most curious circumstances in this case is that the symptoms connected with it, very much resemble those occurring ordinarily in softening of the brain. Thus, the disease commences by a cephalalgia fixed to one point of the head ; then the intelligence becomes impaired; subsequently the limbs opposite the side of the head affected with pain become gradually weakened, and ultimately the paralysed limbs present a well marked contraction. All these are the signs of softening of the brain — still not the slightest trace of this alteration; nothing being found but a collection of blood between the dura mater and arachnoid, the latter being also thickened and diseased. Case 5.—Partial Meningitis—Erysipelatous phlegmon of the neck supervening on a contusion of this part—Signs of arachnitis only during the last hours of life. A postilion, thirty-three years of age of a strong constitution, received, on the 2d February, 1822, on the right side of the neck, a very heavy sac of oats, which fell on him from a height of several feet. He, however, continued his customary occupation till the 7th. He felt a painful tension on the right side of the neck, at which part the skin assumed an erysipelatous appearance; fever came on, and the patient kept his room. The fever continued on the 8th, 9th, and 10th, and the erysipelas spread. On the 11th he entered the hospital, when the fever was very high ; the neck was covered with leeches. Desquamation commenced at several points of the skin of the neck ; but on the right, behind the sterno-mastoid mus- cle, an obscure fluctuation was observed ; this muscle also seemed more prominent than that of the opposite side; no other morbid symptom ; no stool for three days. At one o'clock in the morning the patient suddenly became delirious. On the 12th, at eight o'clock, the delirium'still continued ; eyes haggard, constantly roll- ing ; pupils very much contracted ; violent screams; free motion of the limbs; pulse frequent and very weak; tongue moist and red; burning thirst, no stool; some leeches applied the preceding day still bleeding (blister to one thigh, sinapisms to the legs, purging enemata, acid drink). Three hours after the visit he expired. Post-mortem.—Arachnoid and pia mater natural in every respect, except for the space of three fingers' breadth in length, and two in width, near the anterior extremity of the upper surface of the left hemisphere of the brain. There the membranes were thickened and red. A small quantity of limpid serum in each lateral ventricle ; the posterior part of the two lungs infarcted ; the mucous membrane of the stomach presented, at the pyloric portion, a slight brownish 20 ANDRAL'S MEDICAL CLINIC. tint; the spleen very soft; a great quantity of pus infiltrated the cellular tissue beneath the sterno-mastoid muscle of the right side. Remarks. — This is a very remarkable case. It is probable that the partial arachnitis, ascertained in the dead body, commenced only with the delirium ; the disturbance of the intellect, and a striking contraction of the pupils, were the only two phenomena occasioned by this inflammation; at times these very slight inflammations of the meninges are sufficient to disturb the intellect. We may note also, that here the inflammation was seated at the anterior and supe- rior part of one of the cerebral hemispheres, where, in fact, several physiologists more particularly place the seat of intellect. But why this contraction of the pupils ? What relation between an irritation so slight, and so well circumscribed, of a very small portion of the meninges, and the movements of the iris? The nervous centres may then be injured in their functions, without the anatomist being able to discover any alteration. Case 6.—Acute meningitis limited to the convexity of the left hemisphere of the brain —Delirium.—Convulsive movements of the face and extremities of the right side. A tailor, thirty-seven years of age, had been sick for four or five days when he entered the hospital, 17th July, 1821. On the 15th of this month, without any known cause, he was seized with violent pain of head, particularly seated in the frontal region. On the day after, the headache continued, and the pain became more general, being extended now to the parietal and occipital regions. On this day he lost his appetite, and vomited some drink he had taken. In the evening constant nausea still appeared, followed from time to time by a throwing up of some bitter yellow matter. On the 17th, the headache still continued, but the vomiting ceased ; some nausea still. Having entered the hospital, he presented on the next day's visit, the following state : — face remarkably pale ; pain of head, the precise seat of which cannot be pointed out by the patient; at inter- vals this became so very severe as to make him utter piercing cries; eyes dim and languid ; slight involuntary motion of the muscles which move the commissure of the lips; his answers accurate ; gives a perfect account of his state, and of every thing which happened to him since the commencement of his illness; the pulse moder- ately frequent, and regular; everything else natural. It was difficult to assign a precise seat to this group of symptoms ; the first complaints, however, regarded the head; the vomiting might be considered as connected with a commencing cerebral affection, and the severe headache seemed to point out the head as the seat of the disease. The absence of any morbid phenomenon, with respect to the alimentary canal, repelled the idea that the headache was sympathetic of gastro-intestinal irritation. The ab- sence of all febrile disturbance precluded the possibility of its being mere continued fever. The state of the patient, however, appeared very alarming; the appearance of his countenance, and, amidst this absence of local symptoms, the great alteration already of his fea- DISEASES OF THE ENCEPHALIC MEMBRANES. 21 tures, obliged us to form a rather unfavourable prognosis. M. Ler- minier suspecting a state of encephalic congestion, applied, notwith- standing the extreme paleness of his face, twenty leeches across each jugular vein. Demulcent drinks, and sinapisms to the lower extremities. No change in the patient on the following morning. On the 20th, he was very much cast down, and answered ques- tions with difficulty and reluctance: light was painful to him; he kept his eyes closed, and his head concealed under the bed-clothes; face very pale; pain of head not great; the convulsive movements of the lips more frequent and more marked ; pulse and skin natural (blister to the nape of the neck). In the night he emerged from a state of stupor, in which he had been for the last twelve hours.— He got up out of bed suddenly, saying that some persons were pur- suing him to do him harm. He raved during the night, and occa- sionally uttered several piercing cries. On the 21st, he was kept in bed by force. The face had now become red ; the head was agitated by a continual movement, which carried it from right to left, and left to right; the muscles moving the lips, the alae nasi, and the eyebrows, were in the highest degree of convulsive agitation; saliva, slightly frothy, flowed.in great abundance from the mouth ; he spoke incessantly and with energy, but his articulation was unintelligible; great subsultus tendinum, which prevented the pulse from being felt; its frequency did not seem very great (bleeding from the arm, twenty leeches to the neck, cold applications to the head). No change on the 21st. On the 22d, violent delirium; convulsive motions of the mus- cles of the face: risus Sardonicus; continual motion of the right arm, subsultus increased ; pulse more frequent; tongue moist and red (two blisters to the thighs; ice to the head). On the 23d, head turned back, and to the right; strong contrac- tion of the right arm ; respiration very irregular ; occasionally accelerated ; it then becomes slower than natural. The patient silent and quite still; eyes fixed, and void of expression; mouth open and unmoved; pupils neither contracted nor dilated ; answers no questions; does not even seem to understand them; original paleness of face returned ; pulse sixty a minute, and regular ; bowels not free; tongue cannot be seen; teeth not dry. He remained quite torpid during the day, but at night violent delirium reappeared ; uttered very loud cries. On the 24th, this excitement was succeeded by profound coma ; extremities cold ; a clammy sweat covered the face; respiration rattling. He died in the course of the day. Post-mortem. — On the upper surface, a considerable difference in the colour of the two cerebral hemispheres, the right being pale, whilst the left presented a well-marked red tint, which resided entirely in the subarachnoid cellular tissue, which was traversed by numerous vessels; neither serum nor pus in this tissue-; the grey substance constituting the most superficial portion of the convolu- tions of the left hemisphere participates in the injection of the pia 22 ANDRAL'S MEDICAL CLINIC. mater covering it. The ventricles contained scarcely two tea-spoon- fuls (cuillerees a cafe) of serum ; nothing remarkable in the rest of the brain. The lungs infarcted posteriorly ; the heart contained in its right cavity a large fibrinous clot, deprived of its colouring matter ; the mucous membrane of the stomach very thin towards its great curvature, Remarks.—This case presents an example of acute meningitis more expensive than the preceding case, but still partial; it occu- pies, in fact, but one of the sides of the brain, the median line accu- rately limiting it. The first symptom was pain of the head, which was of long duration and remarkably severe. This, after a little, was complicated with gastric symptoms, which appeared entirely the sympathetic result of the brain affection. The nausea and vo- miting arose from the disturbance of innervation, but these sympa- thetic phenomena soon disappeared.1! The brain symptoms gradually became worse. The intellect, also, so perfect when he entered the hospital, became gradually disturbed. The slight convulsive move- ments of the lips were soon succeeded by convulsions of the entire face and of the right arm, which latter was ultimately found to be permanently flexed. This disturbance in the motion of the right arm might cause us to anticipate that the opposite side of the brain was the seat of the disease ; the pain of head not being confined to the affected part of the cerebral membrane, could not assist in deter- mining it. The therapeutic means adopted seemed to have had no influence whatever on the disease. A little more blood than natu- ral, accumulated in a circumscribed portion of the pia mater, was enough to destroy the nervous functions, and ultimately life. Case 7.—Meningitis limited to the anterior extremity of each cerebral hemisphere— Rosy tint and slight softening of the subjacent grey substance—Follicular enteritis proceeding towards a cure—Symptoms of ataxic fever. A boy, seventeen years of age, entered the hospital February 18th, 1824, with symptoms of slight continued fever; headach ; tongue white, moist, slightly red at the point and edges ; thirst considera- ble ; constipation ; no change in his state for the five or six days fol- lowing, during which interval he was bled from the arm, and twenty leeches were applied to the anus. On the 24th, we were struck with the air of distraction in the patient's countenance ; he answered questions with difficulty, and appeared to be absorbed in thought. On the 25th, he was sutfk in stupor; pupils perceptibly dilated ; tongue natural; pulse small and frequent; skin hot (twenty leeches to the neck). During the two following days no change. On the 28th he emerged from the stupor, became restless, and spoke continually. March 1st, stupor returned ; dilatation of the pupils extreme; tongue quite natural; pulse very small and frequent; notwithstand- ing the torpid state of the patient, the cutaneous sensibility was very much increased ; he complained whenever we touched the DISEASES OF THE ENCEPHALIC MEMBRANES. 23 skin, particularly on the thorax and abdomen ; he pushed the hand which touched him, and complained of pain (leeches again to the neck, and blisters to the legs). He died the next night. Post-mortem. — Fulness of the veins traversing the convexity of the cerebral hemispheres; the portion of the pia mater covering the anterior extremity of each of the hemispheres very much injected ; rose-coloured tint, together with slight diminution in consistence, of the cortical substance in contact with the pia mater at this part of the brain. No other appreciable alteration in any part, except that the lungs contained some small granulations not resembling thoseusually met with, which, when cut into, allowed a small quantity of limpid serum to escape. The inner surface of the stomach was very white, except one small spot, which was red, and seemed formed by the aggregation of small vessels finely injected. In the small intestines several of the follicles were more developed than natural; some single, and others aggregated together, constituting what are called Peyer's glands ; they presented black points, and projected some- what beyond the level of the mucous membrane. Remarks. — This is another case where inflammation of the mem- branes existed only in a very small extent of the external surface of the brain. The pia mater was injected merely towards the anterior and upper part of each hemisphere ; and in this part the grey sub- stance of the circumvolutions participated in the irritation of the membrane covering it. This is all that was found to explain the serious nervous disturbances which manifested themselves on the last days of the patient's life. No doubt but the patient died in consequence of the lesion of the nervous centres. The entire disease, however, did not reside here ; for, on entering the hospital, nothing manifested itself but mere continued fever, without any well-marked local symptom; the intestine was then diseased, and we doubt not but that, at first, there was follicular enteritis, which was in progress of cure, as appeared from the post-mortem ; then the partial menin- gitis supervened, which rapidly gave the most serious character to a disease till then mild. Case 8.—False membranes of recent formation on the arachnoid, lining the convexity of the left hemisphere—No other appreciable lesion of the meninges—Headache at the outset—Delirium—Tubercles in the lungs and spleen. A man, forty-three years of age, entered the Hospital La Pitie at the commencement of the month of April, 1831, presenting the ordinary symptoms of pulmonary phthisis. On the 19th of May he complained of an acute pain, seated in the left temporal region.— This pain, which was not increased by pressure, became occasionally insupportable, and then radiated towards the parietal and orbital regions of the same side of the head. This was the first time he complained of such a pain; it had appeared the night previous, and prevented him from enjoying a moment's sleep. No other change in the state of the patient; the pulse was, as we usually found it in the morning, from 70 to 80; no appreciable disturbance in sensa- 24 ANDRAL'S MEDICAL CLINIC. tion or motion. This pain, then single, and unaccompanied by any other symptom, was considered mere temporal neuralgia, and nothing particular was prescribed. However, the following day and night the patient suffered dreadfully in the temporal region. — On the 20th of May, though seeing no reason to change our diagnosis, we had him bled from the arm to twelve ounces; the blood, exa- mined the next day, consisted of a small clot, rather black, without any appearance of the buffy coat, and encompassed by a great quan- tity of serum. The pain of the left temple had not diminished ; no other new symptom manifested itself. On the 21st, still headache ; no change at all; twenty-four leeches were applied to the left mas- toid process, which bled freely, but the headache is as intense as ever. Conceiving the affection to be a neuralgia, we applied an opium plaster to the left temple, and ordered a grain of hyoscyamus to be taken internally. On the 23d, 24th, and 25th of May, no change; but on the 26th we remarked, for the first time, that the skin of the two eyelids, as also those of the cheeks, was raised by serum accumulated in the cellular tissue; this skin preserved its natural colour ; headache continued ; the pulse was, as usual, 80 ; a blister was applied to one of the lower extremities. On the night of the 27th, the intellect disturbed for the first time, he arose from bed, and became very noisy. Towards morning the delirium ceased, and at the visit we found him as usual, except that he complained less of the temple. On the night of the 28th, the intellect again disturbed, and delirium returned ; in the morning he answered questions very incoherently ; the oedema of the lace increased, without the skin being red ; pulse 88, and the tempera- ture of the skin raised. In the course of the day the patient became comatose, and died on the 29th. Post-mortem, twenty-nine hours after death. — The cranium being raised, and the dura mater divided, we found covering the convexity of the left hemisphere of the brain, at the point of union of the middle and anterior lobes of this hemisphere, a whitish false membrane, soft and not yet presenting any character of organisation, and merely in apposition with the arachnoid, to which it did not adhere. This false membrane was somewhat broader than a dollar. On other points of the arachnoid, of the same side, there were depo- sited as it were small drops of white, thick pus, which we raised on the back of the scalpel. Two or three such drops were found on the portion of the arachnoid covering the left surface of the great falx cerebri; no other appreciable alteration in the arachnoid or brain. In the thorax were numerous tubercular masses, some of which were softened. The internal surface of the stomach pre- sented a slate-colour tint, with papillary thickening of the mucous membrane along the great curve. About a quarter of the spleen converted into a large tubercular mass. Remarks.— This is one of those rare cases wherein the arachnoid, properly so called, is the seat of the disease. It is in fact in its cavity that the morbid products existed. On the right every thing DISEASES OF THE ENCEPHALIC MEMBRANES. 25 remained in the most natural state. It is a case of real arachnitis, similar in every respect to inflammation of serous membranes else- where. This inflammation of the arachnoid will easily explain the different nervous symptoms during life. Thus the pain which affected the left temporal region so long and so severely, was not a mere neuralgia. It marked the commencement of the arachnitis, and for a long time continued alone, and it was only towards the end, that more decided symptoms of arachnitis appeared, first deli- rium and then coma, which was followed by death. Case 9.—Partial meningitis—Tubercles in the pia mater, and in other organs; adhe- sions of two circumvolutions—Headache at first; afterwards delirium; contraction ot the muscles of the neck; paralysis of some muscles of the face. A man, nineteen years of age, on entering the La Charite, com- plained of a violent headache, principally seated towards the right temple, under which he has been labouring now twelve days. His intellect perfect; he constantly lies on the left side. Pulse slow (sixty a minute); the pupils a little dilated ; countenance expresses an air of indifference ; tongue natural; has some difficulty in pass- ing urine. This group of symptoms make us apprehend the deve- lopment of a cerebral affection ; he was ordered to be bled from the foot, and forty leeches to be applied to the neck. The day after (14th March) the air of indifference was succeeded by complete delirium ; the head remained constantly inclined to the right; pulse now seventy-two. He was bled from the arm. In the evening he can now answer questions tolerably, which he could not in the mornino-. When we attempt to incline his head to the left, he evinces°pain; the right side of the mouth then opens, whilst the left half remains unmoved. March 15th. Look fixed; head still inclined to the right; deli- rium still continued; air of stupor; pulse more frequent than on the preceding days; tongue natural; abdomen free from pain: no evacuation by stool (thirty leeches to the neck, laxative enema).— Whilst the leech-bites were still bleeding, the pupils, which till then had remained dilated, contracted in a very remarkable manner. The pulse became very frequent, irregular, and small; the mouth became filled with foam ; the tracheal rale set in, and the patient died at half-past twelve at noon. Post-mortem. — The pia mater covering the upper surface of the cerebral hemisphere, contained about twelve small whitish granu- lations, the size of a lentil, and of cartilaginous consistence. They were found between the convolutions. On the middle lateral part of the right hemisphere, was observed a bright red injection of the pia mater, for a space as large as two five-franc pieces put together. Between two circumvolutions of the middle lateral part of the left hemisphere, was found a white tubercle of the size of a large pea, softened at its centre. These two convolutions had contracted inti- mate adhesions, and were confounded with each other. Numerous tubercles in a crude state traversed the lungs. The lymphatic 3 26 ANDRAL'S MEDICAL CLINIC. ganglions of the posterior mediastinum also tuberculated. Three small tubercles in the spleen. Remarks. — Of the alterations found after death in the body of this patient, some were dated from a period long prior to the attack of the disease under which he fell. Such were the tubercles in the pia mater, in the lungs, in the lymphatic ganglions of the posterior mediastinum, and in the spleen. The adhesion also of the two convolutions of the left hemisphere was a lesion of long standing, and prior to the disease observed by us; to explain the latter, then, we have but the injection of the pia mater in a very small portion of its extent, without any other alteration of this membrane, or of any other part of the encephalon. When the lesions were so slight and the symptoms so severe, who would dare to affirm that these lesions represented everything that did exist, and that anatomy showed us everything that was materially altered in the nervous centres ? Certain it is that the only appreciable alteration of recent formation, discovered on opening the body, existed in these centres ; and it was here also during life, that the entire disease seemed to reside. For a considerable time it appeared unattended with any- thing serious; and obstinate headache, situated towards the point where, after death, we found the pia mater injected, was for the first twelve days, the prevailing symptom. When we saw the patient, his intellect was perfect, his faculties of motion and sensa- tion were unimpaired, and he had no fever. Still from the very first we were struck with his position when in bed, and this phe- nomenon, added to the air of indifference expressed in his counte- nance, directed our attention to the brain. On the following days the disease, which had been at first mild, was accompanied by most marked and alarming nervous symptoms. Delirium, partial paraly- sis of the muscles of the lips, painful contraction of the muscles of one side of the neck, particularly engaged our attention. Whilst these phenomena were developing themselves, the pulse became accelerated, the tongue preserved the most natural appearance. In this case the most active antiphlogistic treatment was employed. During the three days the patient remained in the hospital, he was bled twice, and seventy leeches were applied to his neck. Still the most serious symptoms supervened every day, and we shall even remark, at least as a mere coincidence, that it was immediately after the application of the last leeches that the struggle commenced. Had the loss of blood any share in the symptoms which appeared during the last hours of life? we should be inclined to think it had. Case 10.—Milky infiltration of the pia mater on the upper surface of the cerebral hemispheres—Turbid serum in the great cavity of the arachnoid—Suppuration of the pituitary gland—Vegetation on the aortic valves, with production of encephaloid matter at their base—Delirium—Hurried respiration—Pleurosthotonos. A man, sixty-four years of age, was brought to the La Charite on the 27th of May. Those who brought him stated that he was ill for the last fourteen days, but gave no other information regard- DISEASES OF THE ENCEPHALIC MEMBRANES. 27 ing him. On the next day he presented the follow nstate .- Countenance very pale and dejected; lies on his back «de«na around the ankles; delirium; complains continually voice weak and trembling: respiration high, hurried very painful " ^ lher« were some obstacle to the free entrance of the ""E °^ vesicles ; no lesion, however, detected by ^us^lta^";n/eh.en^e§rSv: the air appears to penetrate in every part; the pulse, being very small comrtIts with the strength of the pulsations of the heart, wS ^accompanied with a§well-marked bellows sound ; tongue natural; abdomen soft (diluent drinks, sinapisms) On.the 29th, his entire bodv strongly inclined to the right: the muscles 01 me neck and thole of th! trunk of the same side, being spasmodically contacted prevented the neck and head from being brought into the straight position; still less could they be made to deviate to the eft TfthePse symptoms of pleurosthotonos were joined delirium great dyspnoea, extreme frequency of the pulse, which was at the same time thready. Died at noon. Post-mortem. -Body very much emaciated ; cedema of the lower Cmnum.-The great cavity of the arachnoid contained a con- side able quantity of milky serum; the pia mater lm.ng the upper and lateral surfaces of the cerebral hemispheres was infiltrated with Cid similar to thick cream; no trace of the pituitary gland lo be found n^he sella turcica ; in its place there was a collection of pus.* T/«- Lungs and pleura sound; a little serum in the pericar- diun right cavities of the heart distended by an enormous clot of blood one of the aortic valves had, on its ventricular surface a greyish vegetation, easily detached with the scalpel from the tissue on which i? rested another of the aortic valves had entirely lost its usuS appearance ;'it was changed into a reddish mass and towards rPoinPtPof union with the internal membranes of the vessels, the atter presented an evident fluctuation ; a slight incision was made on the point where this fluctuation existed, and there escaped between the lips of the incisions a chocolate coloured matter, of a so tTsh consistence, like a mixture of blood and cerebral matter. It is more probable that this was blood effused and altered, than the result of a morbid secretion. c Remarks.-In this case, which we had not the opportunity of seeing till a very advanced stage, the membranes were more seri- ously affected than in any of the preceding. First, they were changed to a greater extent; then there was not only hyperemia, but ptrulent secretions on the two surfaces of the arachnoid, and, what is most unusual, suppuration of the pituitary gland. The symptoms first observed were those usually accompanying meningitis of the convexity of the hemispheres. How shall we „ , ■.. *:„„ «<• «wia nrrran which is such as to protect it from injury, • * FT^ethat the?eL^^ome%y important functions assigned to it, with vol. ii., p. 301, where it was wanting. 28 ANDRAL'S MEDICAL CLINIC. account for the pleurosthotonos, whilst the lesion of the membranes was the same on the right and left 1 The principal cause of the difficulty of respiration appears to have been the alteration of the sigmoid valves of the aorta. This was probably the cause of the bellows sound. Case 11.—Purulent infiltration of the sub-arachnoid cellular tissue of the upper and inner surface of the two cerebral hemispheres—Bright red injection circumscribed to the middle lateral portion of the left hemisphere—Tubercle in the brain—Pain of head ; hemiplegia of the right side ;. dulness ; vomiting ; infrequency of pulse. A boy, seventeen years old, felt for the preceding fifteen days vio- lent pains of the head, and experienced for the last two days only commencing weakness in the lower extremity of the right side, when he entered the hospital on the 24th July, 1822. His state then was as follows: — Countenance very pale, slightly puffed : pupils natural; vision and intellect perfect; the lower extremity of the right side seems to the patient heavier than the left. Since the preceding night only he began to feel some difficulty in moving the upper extremity of the right side, and it seems heavier to him than the other; the sensibility of both these limbs, however, is unim- paired; pain of head very acute, and occasionally extorts loud cries from the patient; pulse irregular, but not frequent: respiration laboured, and the intervals between each inspiratory movement unequal (twenty leeches behind each ear, sinapisms to the legs). A few hours after the visit the patient fell into a profound stupor. The following morning, 25th July, the coma disappeared; intellect perfect; answers precise; pain of head continues ; paralysis of the right side increased; pulse very irregular, and fifty each minute; vomited a green bitter matter twice or thrice during the night; tongue still the same (thirty leeches to the neck, two blisters to the legs). On the visit of 26th sunk into a profound coma; his coun- tenance, however, indicates pain, when the limbs are pinched ; pulse preserves its slowness and great irregularity; skin cool and moist (a blister to the nape of the neck). On the 27th, eyes open, but immoveable; vision appears to be gone; he seems not to understand any thing; and articulates not a word (stimulating frictions to the limbs; ice to the head: sinapisms to the legs). On the 28th, pulse ninety-six. On the 29th, other symptoms appear; the eyes and face are become the seat of slight convulsive twitches, which are repeated at short intervals; coma not increased; he stares at those questioning him, without answering; distinguishes objects well; complains very much; retracts the arm a little when it is pinched ; this arm when raised falls as an inert mass, whilst he holds the left arm raised without any effort; pulse eighty; the respiration propor- tionally more accelerated than the circulation (ice to head conti- nued). On the 30th, the intellect returned, the patient answers ques- tions, hears and sees perfectly; pulse ninety-two, and the respiration still accelerated ; paralysis of the right side continues. On the 31st, the patient, whose state for the last two days was so perceptibly DISEASES OF THE ENCEPHALIC MEMBRANES. 29 improved, relapses into coma ; during the day the respiration, which is no w accompanied with a rattle, becomes more and more accelerated, and the patient expired, as if in a state of asphyxia, during the night. Post-mortem. — The pia mater covering the upper surface of the two hemispheres was infiltrated with a thick purulent layer; the arachnoid itself being in its natural state. On the left, below the pia mater, near the great interlobular fissure, several circumvolu- .tions present a bright red appearance ; some even present a uniform red tint; the tissue of the circumvolutions in other respects natural; outside the left lateral ventricles, on a level with the ancyroid cavity, the cerebral substance contains a tubercle the size of a large pea, developed in a mass of grey substance. Tubercles were found in. great numbers in the two lungs. Remarks. — In this case the membranes were not only injected, they were also the seat of purulent secretion. One of the most striking of its symptoms was the paralysis of one side of the body, which developed itself from the commencement of the disease, and went on increasing. It seemed as if the left hemisphere of the brain was subjected to some compression, and yet such did not appear. The purulent layer between the arachnoid and brain was on both sides ; on the left only some- of the circumvolutions participated in the irritation of the membranes, inasmuch as they were considerably injected. If that were the cause of the paralysis, why was it not preceded by a state of contraction of the limbs, as happens \ery often in inflammation of the cerebral pulp 1 Beside this permanent symptom we find others remarkable for their appearing and disap- pearing alternately; thus the intellect went and returned ; the very evening before death it was quite perfect; still it is very pro- bable that these lesions in the pia mater, which we discovered the following day, existed at that time. Several times also the patient fell into a state of coma, which is considered as appertaining to inflammation of the meninges covering the lower surface of the brain ; and this coma was also moveable as the delirium. The sight also went and returned. Was it not strange that these func- tional disturbances were but transient, whilst the lesions causing them were permanent? In such a case it must be admitted that these symptoms depended less on the cerebral membranes them- selves than on the way in which the cerebral pulp was affected at different periods of the disease by the irritation of the membranes enveloping it. Thus in pericarditis the variability, mobility, and oftentimes also the transient nature of the symptoms, depends on this, that the heart in all persons, or in one and the same person, during the entire course of the disease, is differently affected by the irritation of its investing membrane. — No alteration in the pul- monary parenchyma, nor in its investing membrane, accounted for the very great disturbance of the respiration that was observed.— The symptom, as also the vomiting that took place, must have depended on the cerebral affection. 3* 30 AXDRAL'5 MEDICAL CLINIC. Case 12.—Abuse of spirituous liquors—Pleuro-pneumonia at the outset—Febrile de- lirium—Employment of opium in a large dose—Purulent infiltration of the sub- arachnoid cellular tissue of the convexity of the hemispheres. A coachman, forty-eight years of age, addicted very much to alcoholic liquor, was received into the La Charite on the 25th of September. He then complained of a pain below the left mamma. On the posterior and inferior part of this side, a well-marked crepi- tating rattle was heard, and the sound in this part also was dull.— . The patient coughed frequently, and expectorated transparent viscid sputa, which were slightly streaked with blood. He had considera- ble fever. Three days previous, this person, being till then in good health, was seized with a violent shivering; then pain of side, oppression, and cough became manifest. These symptoms of pleuro- pneumonia were met by bleeding from the arm to sixteen ounces, and the application of twenty leeches to the side, which was done immediately after the bleeding. The blood taken from the veins exhibited the buffy coat. On the following day there was an evi- dent amendment. On the night of the 26th the patient was suddenly seized with delirium. On the 27th, the delirium still continued; the general symptoms of pleuro-pneumonia were gone. Fever still. He was bled to twelve ounces; blood buffed. His state on the 28th still the same (thirty leeches to the neck). On the 29th, delirium still continued. Guided as well by the exist- ing symptoms, as also by knowing the previous habits of the patient, we began to suspect that the case was one of delirium tremens; we determined to try opiates, and ordered ninety-six drops of Rous- seau's laudanum to be given in two doses. He took the first with- out any perceptible effects; in two hours after he took the other, and soon fell into a tranquil sleep till the following morning. He awoke at the visiting hour, and answered, with precision, the ques- tions addressed to him, and again fell asleep ; he awoke in the after- noon in the full possession of his reason. On the 1st of October there was considerable fever, which was accounted for by pulmo- nary engorgement, detected in the posterior and left side of the chest, the crepitating rattle being distinctly heard here ; the use of opiates was suspended. On the 3d, the crepitating rattle was still heard, and in the evening the fever was much increased. On the 4th, the pulse very frequent, and a tendency to delirium reappeared; two blisters to the legs. However, in the course of the day, all tendency to delirium disappeared, and the pulse became less frequent. For three days following the intellect became sound, and every thing so favourable, that he appeared likely to be able to leave the hospital very soon ; when, on the 9th, his intellect again became disturbed, and the pulse was somewhat accelerated ; upon which, an anodyne potion, containing a scruple of laudanum, was prescribed ; two blisters were applied to the thighs, and sinapisms to the lower extremities, but without any benefit. On the 17th, 18th, and 19th, the delirium became complete. On the 20th, the tongue, for the first time, lost its natural appearance ; it became red and somewhat DISEASES OF THE ENCEPHALIC MEMBRANES. 31 dry. The seven days following, continual delirium, increasing pros- tration ; tongue dry and brown ; faeces passed involuntarily ; pulse frequent and small; rapid emaciation of the face. He died on the 27th of October. Post-mortem.— A turbid milky serum infiltrated the sub-arach- noid cellular tissue of the convexity of the hemispheres in consider- able quantity. The lateral ventricles contained but a small quan- tity of limpid serum. In the thorax, cellular bands closely united the pleura costalis, and pleura pulmonalis of the left side. A great quantity of frothy serum gushed out of the tissue of the two lungs ; this tissue also retained the impression of the finger like an cedematous limb. The pericardium adhered closely to the heart by a dense cellular tissue, whose formation must have been anterior to his entering the hospital. Nothing particular in the abdominal viscera,except that the splenic portion of the stomach was consider- ably dilated, and the pyloric portion contracted. Remarks. — When the patient entered the hospital he presented all the symptoms of pleuro-pneumonia, except the characteristic sputa, which were wanting, as sometimes happens. Active anti- phlogistic treatment soon dissipated all the symptoms except the crepitating rattle, which was still heard. Delirium then set in, which was met by venesection, leeches to the neck, and revulsives to the lower extremities. To relieve this state, one hundred drops nearly of Rousseau's laudanum were administered, a mode of treat- ment oftentimes found beneficial where delirium comes on suddenly, in the course of another disease, in persons habitually addicted to ardent spirits. The result was favourable; the patient obtained calm sleep, from which he awoke with his intellect quite sound.— All fever also disappeared ; he now seemed convalescent. Again, however, without any known cause, the delirium and fever returned, and an opiate was again employed; but whether from its being given in too small a dose, or that the functional disturbance was now beyond the reach of opium, the cerebral symptoms continued to become worse, and* seven days after their reappearance, the patient died. It was not probably during these seven days that the morbid alter- ations in the meninges were formed. The pia mater had certainly been the seat of inflammation. Was it so, when the delirium ceased so readily after the first opiate was given 1 We know that opium has, under ordinary eircumstances,the property of exciting cerebral congestion, or, at least, that it produces symptoms which are accounted for by such congestion. We know nothing positive regarding the nature of the lesion existing in the brain, or its mem- branes, on the first appearance of the delirium; nor is it necessary to believe, that congestion is necessary to produce such a symptom : as we know from the post-mortem examinations of several who, during life, had the same symptoms as this individual, and yet no lesion was found to account for them. We think, that in such cases, there supervenes, in the nervous substance, a modification, 32 AXDRAL'S MEDICAL CLINIC. whose anatomical sign escapes us, which precedes either the conges- tion, or the other alterations, which constitute the anatomical cha- racters of encephalitis or meningitis. May not opium, which is mischievous when once the congestion is established, be then administered, inasmuch as, the brain not being in its normal st*te> the opium loses the power of producing congestion in it ? We think it likely thatr if the opium had been administered the second time in as large a dose as at first, on the reappearance of the deli- rium, it would have again succeeded in removing the nervous symptoms. Case 13.—Serous cyst developed in the pia mater—Great quantity of turbid serum in this membrane—Hemiplegia at the age of eight years, which completely disappeared at puberty—Atrophy and debility of the limbs formerly paralysed—Cancerous ulcer of the stomach. This was the case of a man seventy-two years old, who, at the age of eight years, was struck with paralysis of the limbs of the left side, which remained till puberty, and then gradually disappeared ; these limbs continued, for the remainder of his life, much less deve- loped and feebler than those of the opposite side. He also usually experienced in them a sensation of cold. For the last four years of his life his digestion became very much deranged, and he lost all appetite, and without any pain of head or any other part, he gradu- ally wasted away, and died in a state of extreme emaciation. Post-mortem.— The sub-arachnoid cellular tissue of the convexity of the hemispheres was infiltrated with a considerable quantity of turbid serum, and on removing the membranes, the circumvolutions of the two hemispheres appeared farther separated than ordinary by the great quantity of fluid filling up their anfractuosities. Near the great interlobular fissure, towards the middle part of the right hemi- sphere, there was found in the midst of the sub-arachnoid cellular tissue, a serous cyst, about the size of a small apple, which depressed the cerebral substance beneath it. An enormous quantity of frothy colourless serum flowed from the right lung when cut into. The mucous membrane of the stomach presented, at the distance of about three fingers' breadth from the pylorus, a rounded ulcer, about five inches in diameter, the edges of which, formed of mucous mem- brane, were of a livid red colour. In two or three places the parie- tes of the stomach were perforated by this ulcer, and the pancreas was exposed. Remarks.—The serous cyst developed in the pia mater, was here no doubt the result of the lesion which had been in his early life the cause of the hemiplegia in this individual. There was no disturbance of the intellect observed at any period of the patient's life, which circumstance may be accounted for by the slow manner in which the effusion took place.* The fourteenth case given by Andral resembled the above very much, with respect to the anatomical lesions found in the encephalon, except that instead of one there were several cysts discovered- Yet the symptoms differed consi- DISEASES OF THE ENCEPHALIC MEMBRANES. 33 CHAPTER II. DISEASES OF THE MENINGES OF THE LOWER SURFACE OF THE BRAIN. Case 15.—Purulent infiltration of the pia mater covering the lower surface of the brain—Turbid serum in the inferior occipital fossse—Delirium at the commencement of the disease ; subsequently profound coma—Pulmonary tubercles. A tailor, twenty-seven years old, had been for three weeks in the hospital, with all the symptoms of advanced phthisis, when one morning we were struck writh the indistinctness of his answers; rin fact, he seemed as if drunk. The pupils were strongly contracted^ and there was great febrile disturbance; on the following morning he presented the following state ; head turned backwards, nor could it be brought forward, without eliciting screams from the patient; pupils very much contracted; makes no answers; occasionally raves ; some froth at the mouth; teeth closed as in trismus; pulse more than one hundred and twenty ; skin hot (two blisters to the legs). For the four following days the retroversion of the head, and the closing of the jaws, disappeared ; the two pupils remained con- tracted ; on raising the eyelids, we thought the sight quite gone ; he seemed plunged in a profound sleep, scarcely drew back his limbs when pinched. Pulse now but of moderate frequency; skin not very hot, was almost constantly covered with abundant perspiration. The tongue never changed from its natural appearance. The coma however became more and more profound ; the respiration became embarrassed, and the patient expired as in a state of apoplexy. Post-mortem. — We found the entire lower surface of the cerebral hemispheres covered by a thick layer of concrete pus contained in the pia mater; it was found in great quantity, particularly in the fissure of Sylvius, and around the thalamus of the optic nerves.— Five ounces at least of milky serum were effused between the cra- nium and lower surfaces of the cerebellum. Numerous tubercles in different states existed in the lungs. Remarks. — One could not have announced from the symptoms during life, that the membranes at the base of the brain were the exclusive seat of the disease, as nearly similar symptoms were ob- served to exist in cases where the meninges of the upper surface were engaged. MM. Parent du Chatelet and Martinet have given coma as the distinguishing characteristic of meningitis of the base. But this symptom has been observed in cases where the meninges of the convexity were affected. The absence of headache could not be accounted for by the seat of the affection, as the same absence was derably, the intellect being disturbed in the latter case, whilst the power of motion was affected in the other. May this diversity of symptoms, he asks, be explained by the difference in the intensity of the pressure to which the brain was subjected in the two cases 1 — Tb. 34 ANDRAL'S MEDICAL CLINIC. observed where the membrane of the convexity was the seat of inflammation. Neither can the contraction of the pupils be con- verted into a sign, as in diseases precisely similar, both in their seat and apparent nature, the pupils have been observed sometimes con- siderably dilated, sometimes strongly contracted, and sometimes in the natural state; and occasionally contracted on one side and dilated on the other. Acute meningitis is very rarely observed to accelerate the death of phthisical patients. Some of them, to be sure, become delirious a little before death; but no lesion of the brain or its membranes has been detected to account for this symptom. Case 16.—Intense headache with vomiting at first—Tendency to sleep, and disincli- nation to move—Gradual establishment of coma—Natural state of the pupils—Puru- lent infiltration of the pia mater of the base of the cerebrum and cerebellum. Alabouringman,of middle age and strong constitution, on entering the hospital complained of nothing but violent headache, which com- menced five or six days previous, and was for the first two days ac- companied with a painful vomiting. The temples were the seat of the pain ; they seemed as if compressed in a vice; at intervals he felt acute lancinating pains either at the temples or the occiput, and oc- casionally the back of the neck became so painful that the patient could not move: he then presented all the symptoms of wry-neck — he felt easy only when perfectly at rest; appetite gone; and what he ate, he said, gave him no strength: since the invasion of the headache had been but once at stool. We saw him first on the 3d of July, when he presented the following state : — Face pale and dejected; look quite vacant; eyes very sensible to strong light; intellect clear ; pulse and skin natural. The headache the only im- portant symptom in this case (bleeding to sixteen ounces; sina- pisms to legs; purgative clyster); the blood formed into a soft coagulum, with little serum, and no buff. — 4th July. He complained aloud of the violent pain of head ;. he fancied his skull beaten in as it were with a hammer. Still his forehead was cool, and his face paler than the day before ; the pupils, intellect, circulation, natural. Thus the bleeding produced no diminution of the headache— (a se- cond bleeding). On the 5th thirty leeches were applied to the neck. On the 6th headache less ; but he answers questions with difficulty; he lies on his back and remains motionless, and resembles a person going to sleep, or whose eyelids are struggling against sleep. He still retains his intellect, but appears to use it in spite of himself; countenance very pale; features drawn, and as it were fatigued. (Two blisters to the legs.) On the 7th he appears in a profound sleep, will not answer questions; when bid he puts out his tongue readily, which remains white and moist. On being pinched he shows that he still retains all his sensibility; pupils sensible to light; pulse sixty; heat of skin natural. —8th and 9th. Profound coma ; he refuses to open his eyes, and appears not to hear the questions put to him; pupils natural; some sensibility still retained (strong sinapisms to the lower extremities). On the 10th, coma DISEASES OF THE ENCEPHALIC MEMBRANES. 35 still; complete loss of sensibility; yet, notwithstanding this anni- hilation of the functions of the life of relation described by the an- cients under the name of lethargy, the functions of organic life are still perfect; pulse, temperature of skin, and respiration, natural. On the 12th, for the first time, the respiration appeared affected; sometimes very much accelerated, at other times so slow that the respiratory movement just made seemed not likely to be succeeded by another. On the 13th, respiration still accelerated; in the course of the day the tracheal rattle set in, and the patient died in the night. Post-mortem. — The upper part of brain and meninges being minutely examined, no morbid appearance was detected; but on examining the lower surface, the pia mater covering it was infiltrated with a purulent layer from seven to eight lines thick. Chest. — Lungs very much engorged, as the lungs of apoplectic patients, or of animals who die a certain time after a division of the pneumogastric nerves; the right cavities of the heart distended with clots of considerable consistence; the left cavities empty. Remarks. — In this case and in the preceding the lesions found in the dead body were similar, and had the same seat; yet, how dif- ferent were the symptoms in both cases! In the latter case, the seat of the headache was far removed from the place where the autopsy detected the lesion. The several bleedings seemed to exer- cise no influence on the pain in the head; a little after them, the patient, without any previous disturbance of intellect, fell into a state of coma, which every day became more and more profound. Up to the end the pulse continued natural, and it was only towards the termination that the respiration became disturbed, and death seemed the immediate result of the disturbance of this function. The slight disturbance of digestion was but sympathetic. The vomiting, which showed itself at the same time as the pain of head, seemed of the same nature as that which so frequently accompanies the acute hydrocephalus of children, depending equally on disturbance of the nervous centres. The constipation observed in this case is an ordi- nary symptom when the brain is affected. CHAPTER III. DISEASES OF THE MENINGES COVERING THE PARIETES OF THE VENTRICLES OF THE BRAIN. THEcellulo-vascular web extended over the parietes of the lateral ventricles is not visible in the natural state, but becomes so from the effects of disease. Over these parietes may be observed at times large veins filled with blood. We thought this venous engorgement 36 ANDRAL'S MEDICAL CLINIC. coincided pretty often with greater or less collection of limpid serum in the cavities of the ventricles. We never observed on the surface of the parietes of these cavities a fine injection similar to that which appears often on the pia mater around the brain. In more than one case we found, in the interior of the ventricles, either limpid serum in great quantity, or even a milky fluid, pus, membranous flocculi, like those of the peritoneum and pleurae; and in those different cases where there existed within the ventricles so remarkable an alteration in the secretion, the membrane furnishing the morbid product did not itself present any appreciable alteration. These ventricular meningeal inflammations are very seldom found to exist separately ; they most frequently co-exist with meningitis of the base or convexity of the brain, and their symptoms are confounded with those produced by inflammation of the meninges of the other parts of the encephalon. The following cases may be interesting as rather uncommon instances of isolated ventricular meningitis. Case 17.—Sero-purulent effusion into the cerebral ventricles—Cystitis—Violent pain of head at the commencement, afterwards delirium, coma, tongue dry, retention of urine. A man, twenty-nine years old, a saltpetre maker, residing in Paris for the last eight months generally enjoying good health, and regu- lar in his habits, awoke on the morning of the 21st of December with a violent headache, feeling of lassitude, aching of the limbs and anorexia. This state of general uneasiness continued during the following days. He still continued to work till the 27th, when, feeling himself becoming feebler, he kept his bed. On the 31st he entered La Charitf, when he presented the following state:— Countenance pale, features drawn, and as if harassed, eyelids weighed down, air of stupor; violent pain of head, particularly at the forehead, and extending sometimes to the rest of the head; power of motion free; muscular strength still considerable; tongue red and dry; some thirst; disgust for every kind of food; slight pain in the epigastrium, constipation, pulse frequent and tolerably full, skin hot and dry, tumour in the hypogastric region formed by the bladder distended with urine. — (Bloodletting, blister to one leg, purgative enema.) On the following day the state of the patient the same; no stool; the blood drawn presented a soft coagulum without buff. On the 3d, prostration, and air of stupor increased; answers slow and difficult; constantly complains of headache; para- lysis of bladder continued, which rendered the frequent introduction of the catheter necessary; tongue moist; pressing on abdomen caused pain, which might depend on the distension of bladder; still constipation; pulse yet frequent and full (sixteen leeches to neck, twelve grains of Dover's powder, purgative enema). On the 4th no amendment; skin still dry; tongue red, and again becoming dry; the enema had no effect; bladder very much distended (leeches again, and Dover's powder, lemonade, with a little wine added). DISEASES OF THE ENCEPHALIC MEMBRANES. 37 On the evening of the 5th became delirious, and on the following morning he uttered constant complaints ; he said he no longer had pain of head; stupor more marked; tongue red and dry; one stool; urine very abundant, and still drawn oft' by the catheter. On the 7th, acute pain of head; tongue quite dry; pulse frequent, and of considerable strength; skin dry and hot; thirst; delirium. On the 8th, profound coma ; eyes closed; mouth half open ; answered no questions; felt pain when abdomen was pressed; when the skin of one of the extremities was pinched he drew it backhand face assumed an expression of pain. The two arms, when raised, fell back as inert masses; respiration occasionally full and hurried; then became slow, and the respiratory movements succeeded each other at long intervals. The respiratory murmur not blended with any rattle, and its intensity not in proportion to the considerable raising of the thoracic parietes. Pulse one hundred and twenty, and the intervals of the pulsations unequal. Some subsultus in the ten- dons of the muscles of the forearm ; great quantity of urine. In the course of the day the intermissions of the respiration became more and more considerable ; at last it stopped altogether, and the patient expired. Post-mortem. — Several veins in the subarachnoid cellular tissue of the convexity of the hemispheres gorged with blood. On making an incision into the upper wall of each lateral ventricle, an immense quantity of milky serum flowed out, in which some albuminous flocculi floated. On slightly touching the internal wall of each of the ventricles, from the ancyroid cavity to the anterior extremity of their inferior portion, the cerebral substance was found very soft for the space of one or two lines, and seemed as it were diffluent under the finger. Thorax. — Nothing particular. Abdomen. — A great quantity of liquids distended the stomach. We observed on its inner surface two red spots, one the size of a five-sous piece, and the other that of a twenty-sous piece. In the large intestine, veins were seen in considerable numbers in the mucous membrane of the caecum. The mucous membrane of the bladder exhibited a bright red injection in its entire extent; and in several parts it was covered with a purulent exudation. Remarks. — This case resembled in many points, with respect to the symptoms, certain cases of typhoid fevers, to be recorded in another portion of this work. The tongue, which we found in its natural state in the cases preceding this, here presented that redness and dryness so common in dothinenteritis ; the countenance also presented that air of stupor so characteristic of exanthematous inflam- mation of the small intestine. There was no other cerebral symp- tom, properly speaking, except the delirium followed by profound coma, and even those two symptoms appeared only during the last two days. Pulse was constantly frequent, and the skin presented that dryness so often accompanying acute inflammation of the in- testinal follicles, to which part, in fact, one would for many reasons 4 38 ANDRAL'S MEDICAL CLINIC be inclined to refer the seat of the disease, and the cause of the con- tinued fever. Yet the post-mortem disproved this ; what we found being a sero-purulent effusion into the lateral ventricles, with a super- ficial softening of the cerebral substance of a portion of their parietes. We also found remarkable lesions in the bladder, its mucous membrane being every where red, and a purulent layer covering it. Was then the retention of the urine in this case connected with cystitis? or was the latter the result of the repeated introduction of the catheter? If we now recur to the commencement of the disease, we shall find that it began with headache, a symptom, the frequent, though not necessary existence of which we have also observed in meningitis of the base, as well as in that of the convexity of the cerebral hemi- spheres. This having been the first symptom, we had certainly some reason for suspecting the brain or its membranes to be the part affected, yet we could not have been certain of it, particularly when we recollect pain of head similar to this, to have ushered in and accompanied as the leading symptom, different cases of dothinente- ritis. Shall we take into account, in order to establish our diagnosis, the remarkable state of the respiration towards the close! Frank, in fact, has given, as one of the characteristic signs of encephalitis, those long intermissions of the respiration: in this disease, he says, the patient respires deeply, and at long intervals ; Spiratio magna ex longis intervallis ducitur. But the same state of the respiration has been found in several cases of dothinenteritis, without any appre- ciable lesion of the brain after death. Case 18.—Sero-purulent effusion into the lateral ventricles—Granular appearance of the membrane lining their parietes—Alternation of delirium and coma: of stupor and violent agitation ; of abolition of muscular contractions, of strong tetanic twitches— Pulse occasionally rare and frequent. A lapidary, twenty-one years of age, was admitted into La Charite" on the 20th of April, 1820. What particularly struck us then, was his air of dejection; he kept his head under the bed-clothes, and refused to answer questions ; he merely told us that, for several days he had, over the entire abdomen, pains which were not in- creased by pressure, and that for a considerable time he had no stool; pulse not frequent. The nature of the abdominal pains, the consti- pation and apyrexia, together with the circumstance of his being a lapidary, caused us to suspect lead colic. The ordinary treatment of the hospital for this affection was accordingly adopted. On the 21st, skin hot; pulse frequent; the treatment of the pre- ceding day discontinued. Diluent drinks prescribed. From the 21st to 26th, the fever continued; the air of sadness still remains; slight abdominal pains; constipation still; tongue natural (drinks continued; purgative clyster; linseed cataplasms over the abdomen). On the 26th, patient lay on his back, his look being fixed ; the two pupils a little contracted, the right less than the left; head somewhat turned back. He refused to answer questions, and talked DISEASES OF THE ENCEPHALIC MEMBRANES. 39 incoherently; several times in the night he attempted to escape out of bed, so that restraint became necessary. Tongue natural; pulse frequent (two blisters to the legs). On the morning of 27th, profound stupor; patient performs no motion whatever ; abdominal pressure gives no pain; pulse lost its frequency; heat of skin no longer raised; constipation still conti- nues — (eight leeches behind each ear; two blisters to the thighs ; mineral lemonade). On the 28th, comatose state quite gone ; he puts out his tongue when asked, but gives no other signs of intellect; utters not a word ; pupils a little dilated; tongue natural; no stool; apyrexia (purgative enemata, &c). 29th, No change; but on the 30th agitation and delirium as on the 26th; constantly rubbing his hands together; belly tympanitic; pulse not frequent; tongue moist and pale (twenty leeches to neck; twelve grains of calomel). 1st May, delirium continues, retroversion of the head ; carpholo- gy; pupils dilated ; pulse very frequent; abdomen tympanitic (twelve grains of calomel; frictions to the abdomen, with linim. ammon. camphor., and aromatic fomentations to the same part). 2d May, delirium continues, as also the carphology; continual tossing of the head alternately from right to left, and vice versa; moaning; sudden shocks of the trunk and limbs, like those of tetanus ; carotids beat strongly ; the heart raises the parietes of the thorax ; tympanitis considerable. Death at eight o'clock at night, after discharging a considerable quantity of blood from the nose and mouth. Post-mortem. — On a level with the centrum ovale of Vieussens, on each side of the corpus callosum, we perceive a manifest fluc- tuation; an incision made into the lateral parts gave exit to a con- siderable quantity of liquid, like whey not clarified, in the middle of which albuminous shreds are seen to float. From the surface of the parietes of each ventricle, a very thin membrane is detached, which is traversed by very minute vessels curiously injected. On some points of the free surface of this membrane, small greyish bodies exist, the size of a pin's head, like the rudiments of false mem- branes, which, under the form of granulations, are sometimes scattered over the peritoneum. Thorax. — The pleura costalis and pulmonalis adhere by well or- ganised cellular tissue. The lung of this side contained a great number of tubercles, principally miliary, some were larger, and softened. The bronchi of this lung were very red, and the bron- chial ganglia hard and black. The left lung also adhered to the pleura, but contained not a trace of tubercle. The two serous folds of the pericardium were internally united to each other by a false membrane several lines in thickness. Abdomen. — The anterior wall of this cavity projected considera- bly before the thorax; when struck it sounded like a drum. The intestines were enormously distended with gas; stomach contained 40 ANDRAL'S MEDICAL CLINIC. a great quantity of mucus, and the small intestine a great quantity of bile. In the caecum and colon, ascending as well as transverse, the mucous membrane was very much injected. The left lumbar colon, filled with very hard faecal matter, was white on its internal surface, as was the sigmoid flexure and the rectum ; above this last intestine was a very marked circular contraction. The gases and faeces accumulated in the colon could with difficulty get through it; rectum empty. Remarks. — In this patient the nervous symptoms were much more marked and varied than in the preceding. In both, the cere- bral lesion was of the same nature and had the same seat. In the latter case, as in the former, the lesion discoverable by anatomy ex- isted only in the lateral ventricles. With this inflammation of the ventricular membrane coincided different symptoms, some of which are generally regarded as characterising meningitis of the convexity of the hemispheres, and others more especially connected with meningitis of the base; thus on the one hand there was delirium and frequent tossing, on the other a state of coma. We often see these two orders of symptoms replace each other, and at the same time there are observed very remarkable disturbances in the muscu- lar contraction, characterised by shocks of the trunk and limbs like those of tetanus, and a forcible reversion of the head. If we refer to the period when we first saw the case, we shall again find some phenomena worthy of remark, connected with the nervous system. The profound sadness of the patient then, that air of dejection, and disposition to conceal his head under the bed-clothes, as if to avoid our look and questions, his reluctance to answer, &c, were certain indications of a commencing cerebral affection. This state of the patient prevented us unfortunately from procuring any information as to what he had suffered before he came to hospital —as, for in- stance, whether he had had pain of head. The tongue was con- stantly natural, not so in the preceding case ; and yet the primae viae were here affected ; for at different times, and especially on en- tering the hospital, he complained of acute pain in the abdomen, and had most obstinate constipation. Had he the beginning of lead colic ? We must not lose sight of the bright red appearance found in a great portion of the large intestine, and the accumulation of fasces in the sigmoid flexure, which a circular contraction of the com- mencement of the rectum prevented from passing into the latter intestine. This contraction depended on no organic lesion ; it ap- peared to be the result of a spasmodic affection of the muscular coat. Cask 19.—Serous effusion into the cerebral ventricles—Pain of head at the commence- ment—Subsequently coma—Acceleration of the pulse some hours only before death. A mason, twenty-three years of age, had been complaining for several days of violent pain of head, when he entered the hospital. Tongue white ; pulse not frequent: no other ailment than the head- ache. Two grains of tartar emetic were given him. He vomited twice very copiously, and had two stools. The following day the state of the patient underwent a remarkable change. His intel- DISEASES OF THE ENCEPHALIC MEMBRANES. 41 lect very much diminished; he answered questions slowly and with difficulty. Still complained of the headache; pulse and tongue natural. (Twelve leeches behind each ear.) On the 17th. Great stupor. On being very much solicited, he opened his eyes slowly, and looked around him with the most va- cant stare. On being asked how he found himself, he answered, that he was doing very well. Pupils did not contract on the approach of a very strong light; they were not much dilated, the right a little less so than the left. State of pulse and skin natural. (Six teeches to each mastoid process; a pint of whey, with the addition of a grain of tartar emetic, and four drachms of sulphate of soda ; two blisters to ihe thighs; frictions with linim. volat. cantharid. to the extre- mities.) 18th. Stupor continues; utters some unmeaning words; puts out his tongue when asked ; pupils more dilated than on the preceding day, and equally so ; pulse has acquired some frequency; tongue dry ; bladder very much distended— (a pint of whey, with a grain of tartar emetic, and an ounce of sulphate of soda ; frictions with linim. ammon.). During the day the coma increased, and he died during the night. Post-mortem. — The two lateral ventricles were found to be very much distended with limpid serum ; some was also found in the third ventricle. Nothing remarkable was observed in the other cavities. Remarks. — The symptoms here did not differ much from those in the seventeenth and eighteenth cases, in which pus was found to fill the ventricles. There was no febrile excitement at all in the course of the disease, and it was only a few hours before death that the pulse became accelerated. Case 20.—Copious serous effusion into the lateral ventricles—Destruction of the for- nix and septum lucidum—Symptoms of apoplexy. A man, fifty years of age, entered La Charite with considerable anasarca and ascites : no local sign of organic disease of the heart; respiration free ; states that he never felt any pain in the right hy- pochondrium ; the dropsical effusion took place three months previ- ously, but we could not learn from him where it commenced; digestion well performed ; no new symptom presented for the fifteen days following. One morning, on approaching his bed, we found him in a state of apoplexy, totally deprived of consciousness. We were told that since the evening before he had not spoken ; face pale; eyes appeared deprived of sight; both pupils sensibly dilated ; the extremities when raised fall as inert masses; total insensibility; pulse not frequent ; respiration hurried and stertorous; tracheal rattle very loud. He died some hours after the visit. Post-mortem. — Considerable serous infiltration of the upper and lower extremities. Cranium. — A small quantity of limpid serum infiltrates the sub- arachnoid cellular tissue of the convexity of the brain. The two lateral ventricles were confounded with the third into one enormous 4* 42 ANDRAL'S MEDICAL CLINIC. cavity, from which there flowed two glasses full, at least, of serum clear as spring water. In the place of the septum htcidum and fornix, there was nothing but small fragments of a white pulp float- ing amidst the serum. Thorax. — Lungs very much engorged ; in other respects sound. In the heart, which was natural in every respect, and in the rest of the arterial system, there was found but a very small quantity of blood, remarkably liquid. Some liquid blood, and that in small quantity, was all that was found in the veins. Abdomen. — The peritoneum contained several pints of limpid serum. The liver, which was of the ordinary size, was remarka- ble for its great hardness — as also the spleen. Remarks. — Here again we have a considerable effusion of serum into the ventricles, together with a breaking down of the central white parts of the brain. We are disposed to consider the destruc- tion of the septum lucidum and the fornix as the mechanical result of the pressure made on them by the fluid in each ventricle. In the two cases preceding we have seen, notwithstanding the identity of the lesions found after death, that the symptoms were far from being similar. Here again we have the same lesions, and the symptoms were those of apoplexy, that species of it usually called serous apoplexy. Dropsy, of which the cause was obscure, was the only disease the patient laboured under up to the apoplectic attack; and, to account for this dropsy, we found no other lesion, except the morbid state of the liver. There existed already, then, in this indi- vidual, a disposition of long standing to serous effusions ; when suddenly, no doubt, the serous membrane, lining the cerebral ven- tricles, exhaled a large quantity of serum, which caused all the symp- toms of real apoplexy. Thus we have sometimes seen in dropsical patients great dyspnoea suddenly supervene, and" death^follow after some hours the constantly increasing difficulty of respiration. It was accounted for by a serous effusion which took place all at once into both pleurae. In the present case the anasarca and ascites did not diminish when the effusion into the cerebral"ventricles took place. In another individual, whose history shall be given elsewhere, both the anasarca and ascites were considerably diminished before the appearance of the apoplectic symptoms, which, as in the present case, were produced by a sudden effusion of serum into the cerebral ventricles.* * A case somewhat similar occurred in Dublin, about three years since, under my own care. It was that of a man of very intemperate habits, whose liver was considerably enlarged ; he had ascites and anasarca, and was treated in the usual way, without any amendment. One morning when he awoke, he found the size nnifP^J0"^ VCry mr Ch d'm?n,8hed' and the swelling of the lower extremities quite gone. He arose from bed at twelve o'clock in the day, sat a few hours at the fire, became .drowsy, threw himself on the bed, and when his wife went to call him, at about four o'clock in the evening, she found him dead. The ventri- cles of the brain were found to be enormously distended with limpid serum — T DISEASES OF THE ENCEPHALIC MEMBRANES. 43 Case 21.—Considerable serous effusion into the lateral ventricles, with destruction of the septum lucidum and of part of the fornix—Ossification of the great falx cerebri —Symptoms of apoplexy. A man, seventy-two years of age, entered the La Charite during the month of December, 1821. He had been for a longtime labouring under pulmonary catarrh ; for the last two months he kept his bed, being very much debilitated. When we saw him, he had some fever; tongue dry and brownish red ; a little cough in very distress- ing kinks, accompanied with the expectoration of puriform mucus ; intellect sound. He was ordered pectoral drinks, which he con- tinued to use for fifteen days, when suddenly he lost all conscious- ness ; his eyes closed; the four extremities lost the faculties of sensation and motion ; sensibility gone; on raising the eyelids we might touch the conjunctiva without his feeling pain; the pupils were dilated and immoveable ; the pulse retained some strength and considerable hardness, but had lost its frequency; the skin was covered with a copious sweat; each inspiratory movement was ac- companied with a loud tracheal rale. Death took place the follow- ing night. Post-mortem. — Cranium. — More than an ordinary glass full of water filled both lateral ventricles ; no trace of the septum ; in place of the middle part of the fornix, we found a white pulp, which was raised with the scalpel from the upper surface of the choroid plexus. The great falx cerebri ossified. Thorax. —Considerable infarction of the lungs. On cutting into them, a considerable quantity of frothy, colourless serum flowed from their tissue. Slight hypertrophy of the parietes of the left ventricle; numerous incrustations on the inner membrane of the aorta. Abdomen. — A viscid mucus covers in considerable quantity the inner surface of the stomach ; beneath it a bright injection of its mucous membrane towards the great curvature, as also of the small intestine. Remarks. — This is a well marked case of what is called serous apoplexy coming on in an old man, exhausted by chronic irritation of the gastro-pulmonary mucous membrane. In this, as in the pre- ceding case, the patient lived but a few hours after the first symp- toms of apoplexy, during which the pulse retained its hardness, but became very slow ; the slowness depending on the serous effusion into the ventricles of the brain, and the hardness of the pulse on the commencing hypertrophy of the parietes of the left ventricle. Case 22.—Sanguineous congestions in the brain, terminating in serous effusion into the lateral ventricles. A woman, fifty-one years old, of a sanguine temperament and strong constitution, ceased to menstruate about her forty-ninth year ; during the six months following she was subject to a numbness in the right arm. In her fifty-first year she suddenly lost consciousness, fell, and retained, when she came to herself, some difficulty in her 44 ANDRAL'S MEDICAL CLINIC speech, with some falling of the commissure of the lips and tongue on the right side, considerable diminution of motion and sensation on this side, nausea and bilious vomiting. Under proper treatment this state disappeared at the end of four weeks. After this the pa- tient returned to a perfect state of health, when towards the middle of March, 1819, she again began to feel a little weakness in the right arm ; slight pains of head in the frontal region soon supervened, and, on the 26th of April, without any obvious cause, there came on in the night, during sleep, a new attack, more violent than the former, and of the same side; total loss of speech ; considerable di- minution of sensation, but particularly of motion, in the extremities of the right side; features not altered ; tongue fell a little on the right side. This new attack disappeared, however, more promptly than the preceding, and at the end of three days, the patient having entered the hospital, presented the following state : — She had slept well the previous night; some weight of head; tongue unsteady when she puts it out; some numbness and weakness on the right side of the body; speaks distinctly; pulse full, strong, and slow; habitual constipation (lemonade with cream of tartar; fifteen leeches to each foot; warm pediluvium ; purgative enema). In the morn- ing she took some soup, and was seized with vomiting in the course of the day, when she threw up some bile. The vomiting brought on a new attack, followed by an increase of the hemiplegia on the right side and greater embarrassment of speech. She was bled to ten ounces. New attacks of a slight nature appeared in the night, upon which sinapisms were applied to the feet: after this the faeces passed involuntarily. On the 30lh, hemiplegia more developed; articulation nearly impossible; pulse less full, less hard, and more accelerated ; paralysis of the bladder (lemonade with one ounce of soluble tartar ; bleeding from the jugular vein ; purgative enemata; introduction of the catheter). Immediately after the bleeding (ten ounces) a new attack, followed by total loss of speech, and of mo- tion in the right extremities; frothing at the mouth; dilatation of the pupils; countenance quite vacant. On the following morning these symptoms were all aggravated ; trismus also supervened, which prevented her from drinking, and constant drowsiness. On 1st of May, pupils immoveable, blindness, trismus, frothing at the mouth at each expiration; contractility abolished on the right side, almost none on the left; a little sensibility on both sides, rather more on the left; pulse full, hard, irregular for the number of pul- sations (twenty leeches to the neck ; blister to legs; purgative ene- mata). She died a little after the visit. Parl-mortem. — Cranium. — The lateral ventricles contained nearly four ounces of limpid serum ; no lesion in the thoracic or abdominal viscera. Remarks. — The apoplectic attacks in this case seem to have been produced by simple sanguineous congestions in the brain. It would appear that here the hemiplegia was the resultof a sanguineous con- gestion greater in one hemisphere than in the other, whereby this DISEASES OF THE ENCEPHALIC MEMBRANES. 45 hemisphere lost its influence over the muscular contractility, even when the congestion ceased to exist. The first time the hemiplegia was preceded by a total loss of consciousness; the second time it was gradual, and not announced by any symptom of apoplectic attack. The more alarming symptoms observed for the last two days were the result of serous effusion into the ventricles, of w iich the habitual sanguineous congestions had been probably a predis- posing cause. We should not forget to notice here the influence of the vomiting on increasing the hemiplegia. CHAPTER IV. CASES WHEREIN THE ENTIRE OP THE MENINGES WERE INVOLVED. Case 23. — A man, fifty years of age, naturally of a strong consti- tution, having been very unsuccessful in his commercial speculations, came to Paris, where, after residing for some time, he became affected with general debility, which went on daily increasing. At last he entered La Charite on the 11th November, 1821. During the first two or three days he scarcely appeared ill in any way ; but was plunged into a profound melancholy. On the 15th, he complained of total aversion to food; his tongue was covered with a thick yel- low coat; abdomen free from pain ; no fever. During the day he took twelve grains of ipecac, and vomited abundantly. On the following day he seemed better. On the 17th, however, the pulse had become frequent; tongue showed a tendency to become dry; he vomited his drinks; his bladder, distended with urine, formed a tumour above the pubis ; he explained his state perfectly; he was still more sad and taciturn than usual (the urine was drawn off; lin- seed clysters). 18th. Same state of bladder ; countenance exhibits great stupor; still the intellectual and sensorial faculties unimpaired ; patient complains only of great debility; tongue moist and foul; no stool; pulse scarcely frequent; skin not hot — (enema of marsh- mallow with a scruple of camphor; frictions on the extremities with linim. volat. cantharid.). 19th. In the same state. 20th. Pros- tration greater; he lies on his back quite motionless, with his eyes turned up and fixed; he appeared indifferent to every thing passing around him; answers questions precisely, but slowly; pulse frequent; skin hot; tongue still moist (six leeches to the anus; camphor enema, lemonade). On the 21st, for the first time, he com- plained of headache, without being able to point out its precise seat; though he answered questions, still his mind was disturbed at inter- vals; his eyes were constantly directed towards the roof of the bed, except when he was spoken to; tongue, which was very yellow, again showed a tendency to become dry ; abdomen was tympanitic, 46 ANDRAL'S MEDICAL CLINIC. and since the preceding day the feces passed involuntarily -— they were liquid; pulse very frequent and compressible (four leeches behind each ear; fomentation with camphorated oil of camom. to the abdomen; sinapisms to the lower extremities ; infus. quinqum. &c). In the course of the day the faeces passed involuntarily twice; raved all the night. On the 22d, stupor more marked ; eyes, which were directed towards the roof of the bed, were occasionally closed ; mouth half open; no answer could be elicited from him ; tongue very dry, and a dark yellow ; abdomen again soft; on pressing it strongly the respiration was very much accelerated ; pulse ninety- eight, very small, and very irregular; the skin covered with an abundant sweat. On the 23d, eyes dull, features quite altered; pulse one hundred, and thready; skin still hot and moist; passed no urine for the last twenty-four hours. He died in the course of the day. Post-mortem forty-six hours after death — Cranium. — Conside- rable injection of the membranes over the entire convexity of the cerebral hemispheres. Towards the anterior extremity of the inner surface of these hemispheres, the arachnoid was raised on both sides by a purulent layer, which was displaced, but not removed, by passing the back of a scalpel over this membrane. The pia mater was infiltrated with pus through the entire extent of the fissure of Sylvius on the right side; a layer of this same liquid was found on the upper surface of the two lobes of the cerebellum. The upper wall of each of the lateral ventricles was very much raised, and pre- sented an evident fluctuation. Each lateral ventricle contains, in fact, a greyish liquid, in the midst of which numerous flocculi float: these also accumulated in the lower part of the ventricles, form a thick layer which covers the cornu ammonis on each side. Some whitish laminae were also found on the lower surface of the cerebral hemispheres. Thus surrounded on all sides by a layer of pus, the cerebral substance underwent no appreciable alteration, not being even injected. Thorax. — Anterior part of the two lungs empty of blood, whilst the posterior portion was gorged with it. The left cavities of the heart empty; the right cavities contain a small quantity of liquid black blood. In the thoracic aorta is a fibrinous clot divested of colouring matter. The vena cava in the abdomen full of liquid black blood. Abdomen. — The convolutions of the small intestine were dis- tended with gases ; the transverse colon also contains a great quan- tity of them. The stomach, which was covered by the colon and the liver, was distended with a mixture of gas and liquid in its splenic portion, whilst it was contracted in its pyloric extremity; the inner surface of the stomach of a brownish grey, through the whole extent of the great curvature; the duodenum, and two upper thirds of the small intestine, contained a great quantity of a yellow, viscid liquid, which colours very deeply the internal surface, and particularly the valvulae. This portion of intestine, when washed, presents no DISEASES OF THE ENCEPHALIC MEMBRANES. 47 appearance of injection. The lower third of the small intestine contains a greenish matter more liquid, but not viscid; its inner surface is pale, except in three places, where there is observed a deep red colour, the seat of which is in the mucous membrane. Here we found three patches forming a slight projection above the level of the rest of the mucous membrane, each of them being about the size of a five-franc piece. For the extent of four fingers above the ileo-ccecal valve, the mucous membrane was uniformly injected. The large intestine contains a greenish liquid; its inner surface pre- sents through its entire extent a slight injection of the mucous mem- brane. The liver is remarkably large; it extends into the left hy- pochondrium,and is interposed between the abdominal parietes and the spleen, to which it is united by cellular adhesions; its tissue is, in some degree, gorged with blood; it presents a red ground, tra- versed by numerous white lines. Spleen large and very soft. The blad- der, which is contracted, contains not a drop of urine, and its mucous membrane is injected, and on one part of it there is a small eschar. Remarks. — The group of symptoms presented by this individual bear much closer resemblance to those appertaining to a severe dothinenteritis, than to those connected with acute meningitis. On the dead body we found the latter very much developed; but there were also indisputable, though very slight traces of a morbid state of the intestinal follicles. It was certainly on their inflammatory engorgement that those three red marks depended, which projected above the level of the intestinal sarface, the existence of which we found not far from the caecum. We may further observe, that this person had but recently arrived in Paris; on the other hand, he had passed the age at which persons are usually attacked with dothinenteritis. The moral causes which had been operating on him, seemed more particularly to have disposed him to a cerebral affection. In subsequent parts of this work, we shall meet more than one case in every respect analogous to this with respect to the symptoms, in which, however, the nervous centres presented no ap- preciable lesion after death. A question may be raised, whether this meningitis, so remarkable for its extent and for the quantity of pus effused into the pia mater and the ventricles, was not an additional phenomenon, or a complication, and whether it might not have been absent, and the disease still have retained the same form, ob- served the same progress, and been attended with the same severity 1 Several facts, which shall be stated in another place, warrant us in thinking that the question may be answered in the affirmative. Case 24. — Thickening of the membranes on the convexity of the hemispheres, and at their base—Tubercles in these membranes, and in the cerebral substance itself, which is red and softened around them—Tubercular diathesis—Symptoms of apo- plexy at the commencement and termination of the disease. A man, thirty-three years old, had experienced, five days before entering La Charite, all the symptoms of an apoplectic attack; the loss of consciousness continued for twenty hours. On the following 48 ANDRAL'S MEDICAL CLINIC. days he continued paralysed on the right side; then delirium super- vened, and the patient was admitted into the hospital after having been bled three times from the arm. He then presented the follow- ing state: — Face pale; delirium ; equal facility in moving the extre- mities of the right and left side; pulse and tongue natural. On the day after, Feb. 23d, the eighth day of the disease, the delirium still continues; air of restlessness; sinking of the features; pulse hard, still not frequent; tongue white and moist (sixteen leeches to neck). On the 26th, intellect scarcely disturbed; answers slow, but accurate (eight leeches to neck). 27th, Delirium returned; pulse now for the first time has become frequent. 28th, Eight leeches across each jugular vain. On the 2d and 3d of March, delirium complete, with fever (twelve leeches to the neck each day). This state continued with very little change for twelve days following, during which leeches were frequently applied to the neck, when, on the 16th, the patient suddenly fell into a state of the most profound coma; at the time of the visit he seemed like a man who had just had a violent attack of apoplexy. He expired some hours after. Post-mortem. — Cranium. — The arachnoid lining the inner sur- face of the dura mater readily separates from it; the membrane covering the entire convexity of the cerebral hemispheres is opaque, very white, and several lines thick ; the pia mater is the principal seat of this thickening. On the lower surface of the left hemisphere, towards its middle part, we observe in the meninges opaque portions similar in appearance to the meninges of the convexity; but here other peculiarities are also observed; these opaque portions princi- pally exist in the intervals between three or four circumvolutions; the anfractuosity, which should separate them had disappeared, and these circumvolutions closely adhere to one another. On the infil- trated and thickened pia mater, which unites them, there are ob- served small whitish miliary granulations, of a tubercular appearance, set in order like so many beads. In the grey substance of the ad- hering convolutions, there appear several of these granulations; around each of them the cerebral substance is very much injected and softened for the extent of some lines. Thorax. — Similar granulations are also found in great quantity in the substance of the two lungs, and some also in the pleurae. Abdomen. — The inner surface of the stomach white, and slightly injected towards the great curvature; a tumour, the size of a nut, projects on the interior of the stomach in the same direction ; when cut into it was found to consist of a sac, the raised mucous mem- brane forming its parietes, and the cavity being filled with softened tubercular matter; this sac communicated with a large tubercular lymphatic ganglion attached to the great curvature of the stomach. The upper portion of the small intestine a little injected ; some tubercles were found between the peritoneum and muscular coat of the intestine; the mesenteric ganglia very large. In front of the vertebral column there was found an enormous tubercular mass, consisting of the ganglia which exist ordinarily around the recepta- DISEASES OF THE ENCEPHALIC MEMBRANES. 49 culum chyli; the same tubercular ganglia are found in the thorax all along the thoracic duct; a large tubercular mass exists also in the fissure of the spleen ; other tubercular masses fill up the different furrows of the liver; in the interior of the liver we observed seve- ral small round bodies, white, and of considerable hardness, present- ing at their centre a yellow point; similar bodies are found in the central part of the kidneys, but without the yellow point in their centre; three or four of these bodies were also found in the pan- creas. Remarks. — This disease, after commencing with all the symp- toms of an apoplectic attack, entirely changed its form. The apo- plectic phenomena disappeared altogether; not a trace even of the paralysis which followed the loss of consciousness remained. But another scene commenced ; and we behold most of those symptoms develop themselves belonging to the disease designated by Huxham under the name of slow nervous fever. On the part of the nervous centres, we detect no other functional disturbance, except that of the intellect, and even that is not permanent. The disease, after lasting twenty-nine days, returned to its original form, and the patient was carried off in a few hours with the symptoms of apoplexy. The post-mortem examination presented very remarkable lesions. The state of the meninges of the convexity of the cerebral hemispheres, accounts for the disturbance of the intellect, but it does not explain the alternate increase and decrease of the delirium. The lesions at the base were of the same nature as those on the convexity of the brain. We must not lose sight of those red softenings scattered through the grey substance of some of the circumvolutions, and of those precisely whose investing membranes were also diseased.— Was this part of the brain the seat of the apoplexy, in which the dis- ease terminated 1 This appears so much the more probable, as the paralysis was on the right side, and it was at the base of the middle part of the left hemisphere that these softened points existed. But why did the symptoms of apoplexy disappear ? Why did the para- lysis cease? No doubt, because the cerebral lesion, being at first but slight, disappeared of itself. But by reason of the disposition to tubercular secretion existing in this individual, tubercles took the place of the blood that had been effused into the cerebral substance, whilst they were also deposited in the cerebral membranes. At a later period, no doubt a new inflammatory process took place around each cerebral tubercle, and thence perhaps the new attack of apo- plexy which carried off the patient. Case 25.—Pain of head of very long standing—Suddenly delirium ; then coma — Symptoms of apoplexy and death Purulent effusion oh the convexity of the cerebral hemispheres, at the base of the brain and into the ventricles—Old cellular adhesions of the two folds of the arachnoid—ossification of the retina. A shoemaker, thirty-eight years of age, of strong constitution, de- prived of the left eye from his infancy, was troubled all his life with pains of the head, the seat of which he usually referred to the 5 50 ANDRAL'S MEDICAL CLINIC. left side of the cranium ; fourteen months previous he received some violent blows on the head in a fight, since which occurrence his headache became more frequent and more severe; he often feels a dizziness. On the 13th June, after his work, he complained of general illness, and of a more violent headache than ever over the left side of the cranium; during the night he became very feverish. On the 15th he was bled. On the 16th, some delirium at intervals. On the 17th, constant stupor (a blister was applied to nape of neck). On the 18th he entered La Charite, and on the 19th (the seventh day of his illness) he presented the following state: face pale ; eyes shut; appearance of tranquil sleep, from which it is almost impossible to arouse him ; when he does open his eyes he looks around him with a stupid air, utters not a word; power of motion perfect, but sensi- bility diminished; passes his faeces under him — (one ounce of sulphate of soda, sinapisms). On the 20th, no change. 21st, pulse accelerated ; heat of skin very much raised; still comatose ; sub- sultus in both arms; bled from the arm ; blood covered with a thick coat. On the 22d new symptoms were observed; left eyelid remained depressed over the eye; the right eye, on the contrary, wide open, fixed and dull; pupil of this side dilated and immoveable; at each expiratory movement the left cheek was pushed out, announc- ing commencing paralysis of the muscles of this side of the face. The right arm, when raised, fell again as an inert mass; subsultus in the two forearms. Pinching the skin gives not the least pain; respi- ration stertorous; pulse frequent and strong; skin covered with sweat. In the course of the day the coma became more and more profound, and the respiration more difficult, and at five in the even- ing he died. Post-mortem — Cranium. — Cellular adhesions, similar to those often uniting the pleura, extended from the arachnoid covering the hemispheres, to that lining the dura mater. The pia mater, in the upper surface, very much injected. The lateral ventricles were distended by a great quantity of a whey-like liquid. The menin- ges of the brain were generally injected. A thick purulent layer, which was seated in the pia mater covering the left cerebral pedun- cle, the left portion of the medulla oblongata, and extended, like a sheath, over the nerves arising from this part. Nothing remarkable in the thorax or abdomen. Examination of the left eye. — The transparent cornea was thick and opaque; the opening of the iris was completely obliterated by a white membrane several lines thick, the edge of which adhered to the circumference of the iris; no longer any trace of the crystal- line lens. Ihe vitreous humour had a milky appearance. Not a trace of retina, but in its place we found a small bony shell, having a small hole in the centre; its concave surface was applied to the corpus v.treum; no vestige of the ramifications of the optic nerve was discovered on it. The left optic nerve was smaller than the other and of a grey colour, from the sella turcica to its entrance into the eye; it terminated at the central hole in the bony shell DISEASES OF THE ENCEPHALIC MEMBRANES. 51 above described, by a bulb apparently fibrous, and similar to the swelling found in the extremities of nerves in amputated limbs. From their origin to their crossing the two optic nerves were per- fectly similar. Remarks. — In this individual two species of alteration were found within the cranium, and all two had their share in the production of the symptoms. The one of these alterations was of long stand- ing, namely, the cellular adhesions uniting the two layers of the arachnoid. It is very probable, that on these depended the head- aches which so long annoyed the patient. Anatomy, however, does not inform us why the pain of the head was more severe'on the left than on the right. The exasperation of this pain of head, marked the commencement of the acute disease, for which he entered the hospital, and which was sufficiently accounted for by the purulent effusions found on the upper surface of the brain, its base, and in the ventricles. We may observe, that the purulent layer of the base was confined to one of the cerebral peduncles, the left, and also to the left pons varolii and medulla oblongata. We may also observe the purulent sheath, surrounding the nerves, arising from the left side of this part of the brain. Is it in consequence of these anatomi- cal circumstances that, towards the termination of the disease, the left eyelid, and cheek of the same side, became paralysed, at the same time that all motion seemed extinct in the right arm? Violent pain of head, fever, general illness, were all that we observed during the first days of the disease. Some delirium set in on the 4th, which, on the 5th, was succeeded by a state of coma, which went on increasing to the 10th day, when he died, a little after symptoms of paralysis appeared. To explain this succession of phenemena, shall we say that the meninges of the convexity of the hemispheres were, at first, irritated, and that it was then the delirium appeared, and that the coma which succeeded this delirium, announced the exten- sion of the meningitis towards the base of the brain and into the ventricles? We have already seen, however, that it is not always possible to determine from the prevailing symptoms, what portion of the meninges is especially affected. The circulation did not pre- sent that slowness here which it did in other cases. The pulse, which was natural on coming to the hospital, became frequent and febrile, in proportion as the state of coma became more and more developed. We have observed the contrary in the other cases, 52 ANDRAL'S MEDICAL CLINK. CHAPTER V. DISEASES OF THE MEMBRANES OP THE SPINAL CORD. Case 26—Spinal arachnitis—Arachnitis of the base and convexity of the brain— Milky serum in the ventricles.* A woman, twenty-eight years of age, the mother of four children, had been very much distressed by certain insulting proposals made to her; her menses were suddenly suppressed in the midst of their course, and she was instantly seized with violent shivering, which lasted twenty-four hours. The next day, great heat of skin ; burn- ing thirst; a sense of squeezing at the throat; bolus hystericus very marked. On the third day, bilious vomiting; she vomited also * The following very interesting cases, which serve to illustrate the principal circumstances connected with disease of the upper cervical vertebra* are con- densed from Dr. Bright's Medical Reports, vol. ii. part 1, page 415. Thev were communicated to him by Mr. Key : — Case 1.—Slight Paralysis from Disease of the Cervical Vertebrae. A young lady, aged thirteen, had been for about twelve months troubled with pain in the neck, which at first was considered as the effect of a cold. This not going off, was treated by her medical attendant as a glandular affection. This pain continued to increase, until at last she could not rise from the horizontal position without great pain, being also obliged to support her head by placing her hands on each side. When Mr. Key first saw her, she was emaciated, and her counte- nance betrayed great suffering. On examining her neck there appeared a general fulness, which gave her pair, on pressure; she had the power of slightly moving the head backwards and forwards, but the lateral movement was'kccompanied with so much pain that she could not be prevailed on to attempt it. The case seemed evidently an affection of the two upper cervical vertebra. After some time a tumour was perceived at the back of the pharynx, which, on puncture yielded about three ounces of pus, and which Mr. E. concluded had communica- tion with the diseased spine. This gave some relief; but her emaciation and suffering increased About a fortnight before her death, vomiting came on whenever she took food, which was allayed by a blister applied in thi course of the par vagum in the neck; she had convulsive twitchings of the upper extremi- ties, and a slight paralytic affection of one arm. She sunk gradually ,n ill SeC°nid C3Se ffaS,lhat of a y°Ung I"3!1' aSed twenty-three years, who seemed £ labour under an affection similar to the last, with a strong tendency to phthisis Connected with the disease there appeared a tumour in thVneck on the rfSi side' ust behind the angle of the jaw, which projected into the pharynx; on pun*: ur.ng this, a quantity of pus escaped, which gave great relief to his brekth?™ and to his pain The tumour formed again in four da^ys after, and burst,? £ not appear that it gathered afterwards; the external tumour disappeared He complained of some soreness low down in the oesophagus in swallowing there was a slight lateral protrusion of the second vertebras. &WdH0Wlng . there The third case was that of a young man, eighteen vears nlH «-v^ „«^ i • j of great stiffness with swelling at thf back of?h^ neck whichh^H ? P '"^ plaining of for six months, and which was considered rhJamaUe it .M™; rise from the recumbent position, nor move his he.d?withoSch ™£ hW "0t dually wasted away. He expired suddenly, in the act of beTnJ I S'f he gu-" pillow; probably from the anterior ligament ofihew^esT^S^tt0mi.lB moment giving way. A slight tendency to paralysfs of 8„ S " v " was observed on the morning of the day he died — T PP extrem,tles DISEASES OF THE ENCEPHALIC MEMBRANES. 53 whatever drink she took. On the fourth day, still vomits ; hysteri- cal symptoms gone; she entered the hospital in the evening, and on the following morning presented the following state:—fifth day, countenance very much flushed; eyes very bright; neck swollen; head turned back and flexed laterally, could not be inclined forward without causing great pain; constant pain extending along the ver- tebral column, from the great occipital foramen to the sacrum ; the least movement causes the patient to scream from pain; pain not increased by pressure ; respiration embarrassed, and panting; pulse frequent: skin hot and dry; tongue natural; had no stool for the last forty hours (fifteen leeches to the anus; purgative enema; mustard pediluvia; demulcent drinks ; soothing frictions over the spine). Sixth day, pain less (blister to the nape of the neck ; twenty-four leeches behind each ear). Seventh day, sleep disturbed ; increased sensibility of the head and back ; tetanic rigidity of the back of the neck and trunk; countenance pale and expressive of pain; respiration more painful than before; pulse the same (bleed- ing from the arm : blisters to the sacrum; sinapisms to the legs; assafoetida enema). Three minutes after the bleeding, the blood was buffed and cupped; at the end of an hour, the patient very much relieved in every respect, and the bleeding was repeated. Some delirium on the eighth day, when she was bled again. On the ninth, the blood drawn exhibited the same inflammatory appearance as that of the two first days; pain of head and back more intense; features sharpened and very much changed; answers to questions slow and painful—(twenty-four leeches along the vertebral column; laxative enema). At four o'clock in the evening, she no longer answers questions ; constant moaning ; subsultus tendinum ; pulse small and frequent; respiration short. On the tenth day, cold and clammy sweats over the face ; all the other symptoms were aggra- vated, and she died at noon. Post-mortem. — The spinal canal was opened through its entire extent, and on cutting into the dura mater we found a layer ol whitish, opaque, membranous matter extended over the spine, from the great occipital foramen to the sacrum ; on pressing it with the finger, a turbid liquid, mixed with albuminous clots, are made to flow into the cranium ; on drawing the scalpel over this membra- nous layer, the instrument slides on and takes up nothing, which seems to indicate that there is a membrane above this layer; dissec- tion soon proves it. On detaching the arachnoid from the inner surface of the dura mater, we discover thatthe diaphanous membrane covering the purulent layer, is but a continuation of it; it is evidently the portion of the arachnoid which, under ordinary circumstances, covers the pia mater, and which is here separated from it by a layer of pus. Here then the pus is found exhaled, not into the cavity of the serous membrane, but on the external surface of this mem- brane, in the cellular tissue uniting it to the pia mater. On the brain, the arachnoid and pia mater are very much injected towards the fissure of Sylvius. On the right side we find an albuminous 5* 54 ANDRAL'S MEDICAL CLINIC. concretion, similar to that which fills the vertebral canal; we also find another, still thicker, on the external surface of the right hemi- sphere, near the great interlobular fissure. Concretions similar to the preceding are found beneath the tentorium cerebelli, and a still greater quantity than elsewhere between the lower surface ot the cerebellum and the base of the cranium. The lateral and third ventricles were very much distended by a great quantity of milky serum. Thoracic and abdominal viscera sound. Remarks.—This case presents a combination of the different symptoms which characterise, in the most striking manner, acute inflammation of the membranes of the spine. Yet at first, it did not commence by these symptoms ; it might have even been taken for a simple neurosis, and probably it was then nothing more; we think that there are many cases of this kind, and that some inflam- mations are preceded by mere nervous disturbance, in which the disease then entirely consists ; at which moment, narcotics have a marvellous power of" dissipating the symptoms, but if it be allowed to proceed, it will soon change its nature ; and those functional dis- turbances, which, a while ago, were the expression of an affection merely of innervation, will afterwards be produced and kept up by an inflammatory process, where narcotics would be mischievous, and other means must be resorted to. During this first period, which appears altogether nervous, those vomitings also appeared, which are so often connected with cerebral affections, mark their onset, and precede their characteristic symp- toms. It is only from the fourth to the fifth day, after the appear- ance of these different symptoms, that the first phenomena, indica- tive of the nature and seat of the disease, disclosed themselves. The intellect remained for a long time unaffected; whilst, on the contrary, sensation and motion became seriously altered. In none of the preceding cases have we seen anything similar to the acute pains felt all along the vertebral column, accompanied by some tetanic symptoms. Cerebral meningitis also existed; and it is not impro- bable that the inflammation ascended from the spinal canal into the cranium only towards the termination of the case. We are disposed to consider that the difficulty of respiration arose from the circum- stance of the spinal cord, in which we include the medulla oblongata, being the special seat of the disease. The moral cause which brought on the suppression of the catamenia is an additional reason for our considering that the affection, in the first instance, was merely nervous. Case 27.—Spontaneous luxation of the first two cervical vertebra—Hemiplegia. Aman,thirty-fiveyears ofage,of a strong constitution, had always enjoyed good health, except that he twice had syphilis, for which he says he was properly treated. After having suffered considera- bly from pains in different parts of the body, in the left knee, in the region of the kidneys, and ihe left thigh, he was then attacked with pain in the left side of the head, which soon spread to the DISEASES OF THE ENCEPHALIC MEMBRANES. 55 same side of the face; some time after he began to complain of his neck, the motions of which became very much constrained ; about a month after this the patient discharged by the mouth a great quan- tity of pus. The medical man who saw him at this time thought that the purulent discharge came from an abscess which formed between the pharynx and vertebral column, and which opened into the pharynx. However, it ceased at the end of seven days; but from this period the patient's countenance changed rapidly; he wasted away; continued to feel pain in the left side of the neck, his head inclined over the right shoulder, and his face was directed towards the same side. Some weeks after, the fingers of the left hand became the seat of a pricking sensation; the day after they were, as it were, benumbed, and could not be moved without diffi- culty ; the day following, the entire upper extremity of the left side was deprived of motion ; next day he felt the lower extremity of the left side a little weaker than the right. He entered the hos- pital on the 10th of June, and presented the following state: lies on his back, head and face inclined to the right, without any sensi- ble contraction of the sterno-mastoid muscles; lancinating pain throughout the left side of the head ; left pupil not so much dilated as the right; conjunctiva of this side considerably injected ; left eyelid hangs a little over the eye; vision equal on both sides; intel- lect sound; total loss of the contractile power of the left arm ; its sensibility entire ; perceptible diminution in the motions of the left lower extremities ; tongue a little red. There was an issue in the nape of the neck, which was still retained. On the day after, the head having been a little deranged from his position during the dressing, and inclined somewhat to the left as also the face, the two extremities of the right side instantly lost the power of moving; they recovered it the moment the head resumed its usual position. On the nights of the three following days, delirium set in, pulse frequent. Sinapisms were ordered. Two days after, at six o'clock in the morning, the patient was in the same state as on the preced- ing days; he conversed quietly with the other patients who were near him, and there was no sign as yet of his dissolution being at hand. At seven o'clock he suddenly lost the facility of speech; his body was covered with a cold sweat, his respiration became remarkably slow, then stopped altogether, and he died at half-past seven. Post-mortem.— 25 hours after death. The brain being examined with the greatest care, presented no appreciable lesion in its sub- stance ; its ventricles were nearly empty; the external arachnoid was considerably injected. Immediately on separating the pons Variolii from the medulla oblongata, we perceived sanious pus of a reddish grey colour flow in great abundance from the great occipital foramen. The transverse ligament of the atlas which.separates the spinal cord from the odontoid process, was entirely destroyed, and this process was in immediate contact with the cord, which being pressed by it was transformed on that part into a soft pap.— 56 ANDRAL'S MEDICAL CLINIC. The entire process was rough and uneven. The superior articulating cavitv of the atlas, on the left side, did not hold by any 'gamen£"J connection or any capsule to the condyle of the occipital bone ; oom presented a dark rough appearance, and were bathed in an im- mense quantity of pus! The left portion of the posterior arch of the atlas was also carious. The inferior articulating process of the atlas, and the superior process of the dentata of the right side, were also separated from one another, and their surface were black and rough. Finally, the left portion of the anterior surface ot the body of the dentata was equally deprived of periosteum, and presented numerous asperities; it was separated from the pharynx by a puru- lent collection of a dirty grey colour, which communicated with this passage by a fistulous opening, the orifice of which corres- ponded to the fourth cervical vertebra. Remarks.— Let us now endeavour to connect the lesions found after death with the symptoms during life, and let us see how far the one may clearly explain the other. In the first place, it is evident that the purulent discharge which took place by the mouth, about two months before death, had the origin ascribed to it by the medical man who saw him at the time ; it is probable that some pus flowed every day through the fistulous opening in the posterior wall of the pharynx ; but coming only in small quantities at each time, it passed probably into the stomach. It is again probable that the disease of the first two cervical vertebras commenced long before it manifested itself by any well-marked symptom; but in proportion at this disease advanced, the different ligaments securing the con- nexions of the occipital bone and the first two vertebras, were des- troyed, gradually, and at last became totally disorganised. As soon as this destruction was carried to a certain degree, the displacement of the articulating surfaces was the inevitable consequence; thence compression of the cord by the luxated vertebras. There was a luxation on the right as well as on the left. The inclination of the head and face to the right shows that the displacement took place principally on the left, at the atloido-occipital articulation : the pa- ralysis also existed on this side. One day a momentary paralysis was noticed on the right side, in consequence of a slight change in the position of the head. This circumstance is easily accounted for, by supposing that in this change of position the diseased articulating surfaces of the right side came to ride one over the other. The permanent inclination of the head without contraction of the sterno-mastoid muscles, might have inclined one to suspect luxation of the vertebrae. The manner in which the head inclined over the shoulder, without the neck seeming to participate in this flexion, as happens in the natural movements, indicated that the luxation took place very high up. It must be admitted that at first the odontoid process underwent but very slight displacement.— But a period arrived when, whether after some sudden movement, or in consequence of the destruction of the transverse ligament, the spinal marrow came to be compressed and disorganised by this DISEASES OF THE ENCEPHALIC MEMBRANES. 57 process. This phenomenon may be referred to the time when the patient suddenly lost the faculty of speaking, and when his re- spiration became embarrassed ; death supervened as soon as the disorganization of the cord was such as to incapacitate it for the discharge of its functions. Some would connect the caries of the vertebras in this case with the syphilitic attack under which the patient had previously laboured. Case 68.*—Phenomena obscure at the commencement of the disease—Constipation— Retention of urine—The fifth day, paralysis affecting the motion of the lower limbs with morbid exaltation of the sensibility—Rigidity of the neck and trunk, accompa- nied with pains along the spine on raising the patient.—The seventh day, the same phenomena in the upper extremities, but in a less degree—They became a little rigid—Symptoms gradually became more severe—Death at the commencement of the tenth day—Puriform exudation between the arachnoid and pia mater of the cord— Injection of the cerebral vessels—Turbid serum in the ventricles. A man, twenty-four years of age, of rather a strong constitution, entered the Hotel Dieu, the 19th of October, 1823, stating that he had been ill for the last five or six days. He complained of no par- ticular part as being the seat of acute pain ; his illness was general, but slight; still his countenance was expressive of suffering ; his answers were slow ; lips seemed to tremble as when a person is going to cry ; no appreciable symptom of fever ; heat of skin natu- ral; no symptoms of gastro-intestinal irritation. He remained for two days without undergoing any change. He arose out of bed and walked through the ward, but not having passed any urine since entering the hospital (three days), the catheter was introduced ; bladder very much distended. On the 24th Oct. (fifth day), M. Dance examined the patient more particularly ; his countenance still expressive of suffering ; seems always as if going to weep ; an- swers slow and vague, when questioned regarding his state, about which he does not furnish any more information; bladder still dis- tended ; on raising the lower extremities he screams with pain, particularly on moving the right lower extremity ; pinching felt equally in both limbs; sensation also perfect, but he cannot raise them; he cannot even extend them after they have been flexed ; they fall back on the bed as inert masses, if left to their own weight; they are deprived of motion but not of sensation. The vertebral region was then examined, which presented nothing unnatural; it was remarked that he could not replace himself on his seat; that he suffered on the least flexion of the spine, and that the neck was slightly retroverted ; on attempting to incline it for- ward, it could be done only to a certain degree, and by causing the patient some pain; he was now very irritable. In the upper ex- tremities motion and sensation underwent no change ; pulse has some frequency and a little hardness; skin hot; tongue natural; no stool for the last five days ; no rigidity nor convulsions in the lower * A few cases of Spinal Meningitis are here added from Ollivier's Treatise on Diseases of the Spinal Cord. The numbers annexed to the cases refer to Ollivier's work. — T. 58 ANDRAL'S MEDICAL CLINIC. extremities (venesection, enemata). On the 25th, same state ^dis- tention of the bladder; pulse frequent; skin hot; limbs painful when moved, particularly that on the right side ; same state of coun- tenance and slowness in the association of his ideas; same pain on turning the patient (another bleeding). On the 26th the same ap- pearance ; pulse now very small and more frequent; bladder still distended ; urine fetid, turbid and reddish, contains a gaseous fluid which is heard escaping by the catheter, which is blackened by re- maining even for a short time in the bladder; blood last drawn buffed and cupped. In the evening state worse ; pulse nearly ex- tinct and very frequent; still the heart beats with considerable strength; lower extremities sensible, but cannot move, and are very painful when any one attempts to move them. This paralysis and morbid sensibility begin to appear in the upper extremities, which present a slight rigidity ; trunk and neck rigid ; countenance still expressive of suffering; answers slow but precise; tongue moist; evacuations from the bowels scanty. On the 27th same state; parietes of the bladder have now lost all contractility ; upper extremities weaker; one stool (sinapisms to lower extremities). On the 28th, patient now much worse in every respect; the con- tractile power of the upper extremities weakened ; they are half- flexed, and evidently rigid, as are the entire trunk and neck ; head somewhat inclined backwards and to the left; right pupil more dilated than the left; respiration slow ; motions of ribs incomplete ; bladder still distended; escape of fetid gas with the urine through the catheter; no stool. Died on the 29th, the tenth day of the disease. Post-mortem thirty hours after death. Cerebrospinal Cavity.— Marked injection and distention of the spinal vessels ; membranes healthy ; lateral ventricles very much distended, containing about three-fourths of a glass of serum, some- what opaque; the other ventricles were also distended. The vertebral canal being opened through all its extent, we observe, external to the dura mater, in the cellular tissue surrounding it, a network of vessels injected with blood. This membrane seemed very much distended and immediately applied to the cord, which already indicated a particular development of the parts contained in it. The dura mater having been cut into through its entire length, the cord appeared covered by a gelatinous layer, slightly yellowish, four or five lines thick, which was applied immediately over the pia mater. This layer was very thick towards the lumbar enlargement of the cord, and there also the yellowish colour was deeper; it gradually diminished in thickness in ascending as far as the third or fourth cervical vertebra, where it ceased altogether ; there was no trace of it on the cauda equina ; it was less thick and less perceptible on the anterior surface of the cord than on the posterior surface. This gelatinous layer was situated between the pia mater of the cord, and the corresponding arachnoid reflexion; that which lined the dura mater was also covered with a very delicate false membrane DISEASES OF THE ENCEPHALIC MEMBRANES. 59 granulated, and of little consistence.' This puriform, concrete sub- stance, subjacent to the arachnoid, was not liquid, whether by reason of its tenacity, or because it was contained in the meshes of the sub- arachnoid cellular tissue. The lower part of the spinal canal, beneath the arachnoid, contained four or five spoonfuls of opaque serum. Thorax. — Lungs adhering at all points of their surface, by or- ganised cellular bands of long standing ; the right lung posteriorly, was evidently in the first degree of hepatisation ; its tissue friable and gorged with blood ; heart natural. Abdomen.—Mucous membrane of the stomach plaited, grey, slate-coloured, and even somewhat blackish,for a considerable por- tion of its extent; in some parts it was studded with red dots, as if from ecchymosis ; that of the intestines was very much injected, red- dish, and the intensity of this colour, which occupied the lower fourth of the intestine, went on increasing as far as the ileo-caecal valve; the mucous membrane of the bladder was thickened, reddish, slate- coloured, evidently inflamed, and filled with thick, fetid urine. Remarks.—This case presents, in a manner, the complete history of spinal meningitis, and the symptoms of this inflammation were, as we see, conformable to the lesions found on the dead body ; the invasion of the disease was obscure ; the patient remained four days in the hospital before we were able to determine what his disease was. The first four days he arose out of bed and walked about the ward ; so that it is evident the locomotive powers were not affected till the fifth day ; up to that period, paralysis of the bladder and retention of urine were the only symptoms that could create any suspicion of lesion of the spinal cord or its membranes ; the func- tions of the intestines were at the same time destroyed, and consti- pation existed nearly from the commencement of the disease till death. Paralysis of the motive power of the lower extremities, with morbid exaltation of the sensibility, are the phenomena which then appeared, and to which were joined rigidity of the neck, inflexi- bility of the trunks, pain in the trunks and limbs on moving these parts. Such was the series of the symptoms which manifested themselves successively in the course of the spinal meningitis. Again, if we consider the peculiar appearance of the countenance, the difficult association of ideas, the slowness of his answers, which were noticed from the commencement, it may probably be supposed that the cerebral lesion preceded that of the membranes of the cord : so in fact it appears to me ; but the changes found in the encephalon, and which are also entirely conformable to the slate of the cerebral functions during the disease, were not of a nature to have influenced the progress of the spinal meningitis; they probably contiibuted to throw obscurity over its first progress. What makes it probable that they could not exercise any influence on the progress of the spi- nal meningitis, is, that the latter manifested itself by symptoms which proved its ascending progression,and its commencement in the lower portion of the cord. It may be remarked, that the neck becoming 60 ANDRAL'S MEDICAL CLINIC. rigid, and the upper extremities losing their strength, were subse- quent to the paralysis in the motion of the lower extremities. The muscular movements were abolished in the bladder, the intestine, and the lower extremities, whilst the upper extremities had lost but a portion of their motive power; and the pseudo-membranous layer was found, in the dead body, much thicker inferiorly than supe- riorly, which seemed to indicate that the inflammation had been of longer duration, and of a less recent date in the former region. The pain felt by the patient on moving the limb or trunk, may, perhaps, be explained by the slight dragging, or shaking, which the inflamed membranes of the cord then suffered ; the same phe- nomenon being also observed in pleuritis, where the slightest pressure increases the sufferings of the patient. The involuntary contractions of the vertebral muscles, which rendered the spine like an inflexible stock, seem also the result of those instinctive motions which we so often execute for the purpose of avoiding or preventing pain. The vertebras, by becoming fixed one upon the other, prevented the spinal membranes from experiencing so much dragging. The morbid exaltation of the sensibility seems to be one of the characters of spinal meningitis. According to Laliemand, the sensibility is not as often abolished as the power of motion, because the nervous centres are in two very different physiological conditions in the production of motion and of sensation ; they are active in the performance of the former, whilst for sensation they are merely passive ; they only receive the impres- sion. The rigidity and semi-flexed state of the upper members ob- served in this case, support M. Lallemand's opinion, who considers convulsion and rigidity of the limbs as a symptom of inflammation of the coverings of the nervous centre. In this case, traces of inflammation were found in the lungs, stomach, and bladder. The state of the lungs may be easily accounted for by the difficulty of the respiration during the last period. The state of the stomach and intestines gave rise to no symptom, except we refer to it the burning heat of skin, and the great thirst. We are inclined to think that those inflammations so often met in these cases are the effect of sympathic reaction, and of the numerous connexions uniting the spinal cord to the respiratory and digestive organs. With respect to the cystitis, it was attributable no doubt to the decomposition of the urine, and to the irritation caused by the sound in the bladder. What was remarkable in this case, is, that the symptoms were con- tinued, those painful tetanic contractions so characteristic in such affections, which come on at irregular periods, and are followed by more or less remission, not having been here at all observed. DISEASES OF THE ENCEPHALIC MEMBRANES. 61 Case 72*.—Permanent tetanic contractions, accompanied with symptoms of cerebral meningitis—Death on the ninth day—Puriform exudation at the base of the left hemisphere, and in the middle of the dorsal region, under the arachnoid—Gelatinous infiltration of the cellular tissue, external to the spinal dura mater. A male child, between three and four years of age, was brought to the Hopital des Enfans-Trouvis. The first symptoms were very great difficulty of deglutition ; remarkable fixedness of the eyes, to which soon joined tetanic symptoms: trismus, opisthotonos. — (Re- peated application of blisters behind each ear, sinapisms to the lower extremities, frictions, tepid baths produced no amelioration.) The child was continually comatose. Died on the ninth day. Post-mortem.— Cranium. — Cerebral substance very much in- jected and firm; the grey substance of a very deep colour; white substance of a pearly aspect, containing some injected vessels, parti- cularly around the ventricles, which contained a considerable quan- tity of serum. Their lining membrane thickened and injected.— That of the lower part of the left hemisphere was covered by a thin albuminous concretion, and the same membrane presented a very bright red injection on the convexity of the two hemispheres, and in some parts of the cerebellum. Spine. — In the middle of the dorsal region, there was a reddish infiltration, of considerable consistence, in the cellular tissue between the dura mater and the bony canal of the spine. On making an incision into the membranes, their cavity was found filled with serum ; the vessels on the snrface of the pia mater were very much injected, in the middle of the dorsal region only, where the arach- noid covered an albuminous concretion of about four inches in length. The substance of the cord a little more injected than natural. Thorax. — The pleura pulmonalis of the right side adhered to the pleura costalis and to the diaphragm by a false membrane of some thickness, and not organised. Abdomen. — The stomach, which was contracted on itself, con- tained some frothy mucus. The mucous membrane of the small intestines also was covered with a grumous whitish mucus. That of the large intestines was of an intense.red colour, through all its extent. The mesenteric ganglia were very large, soft, and white. Liver pale. Remarks.—The spinal meningitis, though circumscribed, contri- buted no douht to cause the tetanic contraction of the trunk in this case ; yet we must also take into account that the cerebral meningi- tis must also have exercised some influence in producing this phe- nomenon, it alone being in some cases sufficient to produce the re- troversion of the neck, It is evident from this case that inflamma- tion of the membranes of the cord may be confined to a portion of their extent more or less circumscribed ; we shall presently see another case fully demonstrating this pathological fact. There was also found a gelatinous and reddish infiltration in the cellular tissue, * Ollivier, vol. ii., p. 585. 6 62 ANDRAL'S MEDICAL CLINIC. external to the dura mater; and I shall here remark, that this change appears to be sometimes the sole product of spinal inflammations. — The existence of thoracic and abdominal inflammation, which is so frequent a coincidence with affections of the spine, is to be set down as a consequence of the physiological and pathological relations connecting this nervous centre with the different apparatuses of or- ganic life. Case 73.*—Deep-seated pain in the lumbar region, after a violent effort; cerebral symptoms followed by debility, and partial paralysis of the limbs; urine and faeces discharged involuntarily—Death twelve days after the appearance of the latter symp- toms—Effusion into the right ventricle; meningitis of the convexity of the left hemi- sphere; capillary injection, of about an inch in extent, beneath the arachnoid of the meningeal sheath of the cord in the lumbar region. A man, twenty-eight years of age, entered the hospital La Chariti, April 4, 1823. He had been treated at the Saint Louis for a deep- seated pain which he felt in the lumbar region, after a violent effort to raise a load in September, 1822. A blister was applied over the seat of pain, which was very long in healing. On entering La Charite, he complained of general debility ; he was very much dejected, and considerably emaciated. On the 7th of the month, he presented the following symptoms: — extreme difficulty in answer- ing questions, inability to articulate certain words; mouth slightly inclined to the right; face a little red ; left arm weaker than the right; sensation and motion of the lower extremities natural; urine and faeces passed involuntarily — (arnica, blisters to legs, purgative clyster). On the 8th, several stools, pulse slow; mouth straight, countenance pale ; unable to articulate one word ; motion of the left arm more difficult than that of the right— (volat. linim. with tinct. cantharid. to be rubbed on the limbs). On the 9th, both arms move equably; loss of consciousness. On the 10th, deglutition impossi- ble ; he manifests some pain when his legs are taken hold of to dress the blisters; respiration frequent, not stertorous. Died at ten o'clock in the morning. Post-mortem (twenty-two hours after death). External appear- ance.— General emaciation: great rigidity of the limbs; chestflat- tened and narrowed. Head. — Vessels of the brain gorged with blood, patches of a yel- lowish grey colour on the surface of the left hemisphere, formed by a concrete substance effused under the arachnoid; considerable serous effusion into the right ventricle. Spine. —Whitish turbid serum (about an ounce and half) in the lumbar portion. On the right side a sort of ecchymosis, an inch broad, formed by a number of small capillary vessels injected, subja- cent to the arachnoid lining the dura mater; the injection deeper in the centre; the arachnoid was neither thicker nor more opaque on this part, which corresponded to about the third vertebra. Its inner * Ollivier, vol. ii., p. 589. DISEASES OF THE ENCEPHALIC MEMBRANES. 63 reflexion was separated from the pia mater of the cord, posteriorly only, by a frothy serum which diminished towards the upper part. Thorax.—Some adhesions of the left lung to the pleura. Its inferior lobe presenting pneumonia in the third stage; pus escaped from it on making an incision ; upper lobe filled with miliary tuber- cles in different dgrees of softening. It crepitated however. — Entire of the right lung adherent, crepitating, filled with grey gra- nulations. Abdomen. — Liver occupies the two hypochondria, concealing the stomach ; it was gorged with blood, Veins of the stomach dilated. Small intestines presented some partial redness in their interior. — Bladder dilated, urine deep-coloured, fetid, not ammoniacal; its mu- cous membrane pale. Remarks. — The continuance of the pain in this case, and the rela- tion existing between its seat and that of this isolated inflammation, incline us to think that the effort made to raise the heavy load had been the cause of it. The patient was in some respect cured of this when he entered the hospital, and died of cerebral meningitis.— The turbid liquid found in the spinal membranes came probably from the cavity of the cranium, being a portion of that which dis- tended the ventricles. The cases now given belong to acute spinal meningitis; and the symptoms, as well as the changes found after death, show what great influence the spinal cord possesses over the organs of nutritive life, in which we very frequently find evident traces of an inflammation which was developed during the course of the spinal affection. But when the meningitis is chronic, its symp- toms are less obvious, consisting merely in obscure pains of the back, with a feeling of restraint and fatigue in the limbs, and the attention is in general exclusively directed to the morbid phenomena which arise from the viscera secondarily affected, the true causes of which are too often misunderstood. Colouring more or less deep of the membranes, and a thickening of them, are the ordinary anatomical characters of this chronic inflammation, which also usually leaves after it cellular adhesions between the arachnoid and pia mater, and between the two arachnoid reflexions. 64 ANDRAL'S MEDICAL CLINIC. RECAPITULATION. CHAPTER I. LESIONS DETECTED IN THE MENINGES BY POST-MORTEM EXAMINA- TIONS. ARTICLE I. Lesions of the Dura Mater. Lesions in the dura mater are much more rarely met with than in the two other cerebral membranes. In the cases already detailed, there are two which present remarkable instances of tumours de- veloped on the inner surface of the dura mater, one of them being seated in that portion of the dura mater which is in contact with the vault of the cranium, whilst the other was formed on one of the two portions of the tentorium cerebelli. These* tumours had a texture analogous to that of the dura mater itself. One of them was constituted exclusively of fibrous tissue. In the other there was mixed with this fibrous tissue, a certain quantity of ossiform matter. Both these abnormal products bore a strong resemblance to the fibrous bodies of the uterus. In the two cases, the nervous sub- stance was rather wasted than compressed, where it was in contact with the tumours. In one of these cases we could not refer the disease of the dura mater to any appreciable cause. In the other case, it was after external violence inflicted on the occipital region, that the tentorium cerebelli became the seat of the osteo-fibrous vegetation already described. Here then is one of those cases wherein we must have recourse to the existence of a disposition altogether peculiar, in order to explain those infinitely varied lesions which one and the same cause is capable of producing. One of our cases presented us with a considerable ossification of the great fold of the dura mater, known by the name of the falx cerebri; this is the part of the dura mater most frequently incrusted with calcareous phosphate. In two cases, where it presented no trace of ossiform substance, this falx was transformed, for almost its entire extent, into a large plate of cartilaginous texture. The very fine cellular tissue interposed between the proper tissue of the dura mater, and that of the arachnoid lining its inner surface, has presented to us some lesions worthy of remark. First, we have * These tumours are different from the fungoid tumours which appear to be connected with the arachnoid of the dura mater; they arise from the structure of the dura mater itself, with which they are intimately joined, and from which they are inseparable without tearing that membrane___Bright, vol. ii. 663. For a highly interesting case of tetano-epileptio convulsions, where a bony deposition was found in the falx, as reported by Dr. James Johnson, see Medico- Chirurg. Review, April, 1835. — T. DISEASES OF THE ENCEPHALIC MEMBRANES. 65 found in it those cartilaginous or bony plates mentioned above, and we have elsewhere* shown that the ossifications of fibrous mem- branes are much more frequently seated in the cellular tissue, im- mediately touching these membranes, than in their own proper tissue. On one occasion we found the arachnoid separated from the por- tion of dura mater corresponding to the arch of the cranium, by small depositions of pus, between which the membranes appeared quite sound. These depositions were five in number, and existed only on the left side : each of them appeared as a white layer, from three to four lines thick, interposed between the arachnoid and dura mater. There was at the same time sero-purulent infiltration in the subarachnoid cellular tissue of the convexity of the hemispheres. We have never met a case of serum being effused between the arach- noid and dura mater.. ARTICLE II. Lesions of the Arachnoid.^ The lesions of the arachnoid, as those of other serous membranes, are principally referrible to its products of secretion. This may be modified in different ways, though at the same time the arachnoid does not receive more blood than usual, and may not have under- gone in its nutrition any appreciable modification. 3 It should not be admitted that the arachnoid has been the seat of a morbid secretion, except when the product of this secretion is found in its cavity. Now this case is itself much more rare than that in which the morbid product is found outside the arachnoid, in the cellulo-vascular tissue constituting the pia mater. The morbid products found in the cavity of the arachnoid are the following:— 1. An effusion of clear, transparent serum. Such an effusion is very rare on the upper surface of the brain; it is more common at the base, towards the occipital fossae. 2. An effusion of turbid, milky serum", with purulent flocculi. We have seen but one instance of this sort in the great cavity of the arachnoid. 3. False mem- branes not yet organised, lining one or other of the free surfaces of the arachnoid. 4. False membranes of longer standing than the preceding, of serous organisation, extended over one or other free * Pathological Anatomy. + The arachnoid and pia mater are so intimately connected as to be scarcely separable from each other, except at the base of the brain. . . . . The arachnoid of the adult in its healthy state is supposed to possess very little vascularity; but its substance is so delicate, that the vessels of the pia mater are distinctly seen through it; and when fluid is effused into the cellular membrane of the pia mater, some of the vessels appear evidently to lie on the surface of the fluid, as if they belonged to the arachnoid, and do not dip down between the convolutions. — Dr. Bright, M. R., vol. ii., p. 669. — T. 6* 66 ANDRAL'S MEDICAL CL1MC. surface of the arachnoid. 5. Adhesions of a cellular appearance, similar to the bands of the pleura?, and extending from one of the free surfaces of the serous membrane to the other. There are some cases in which, instead of any of these anormal products, we have found nothing but remarkable dryness of the arachnoid on the sur- face not adhering. It would appear that in such a case there had been during the last period of life, a suspension of the exhalation of the fluid, which ordinarily gives to this membrane a certain de- gree of polish and moisture. With or without these latter degrees of alterations of secretion, we have never observed in the arachnoid the least vascular injection ; neither have we ever seen in it either change of colour or thicken- ing. It appeared to us that the cases wherein the arachnoid appeared at first view either coloured or thickened, were cases where there were lesion of the subjacent cellular tissue. Whatever be the nature of the delicate membrane lining the inner surface of the ventricles, this membrane presents, in the pathologi- cal state, nearly the same lesions as the arachnoid developed around the brain, but the former are more frequently met with. It is much more common, for instance, to find serum effused in considerable quantity into -the ventricles than into the great cavity of the arachnoid covering the convexity of the hemispheres. The presence of this serum in the ventricles should be considered as the result of a morbid process only when its quantity exceeds an ounce in each lateral ventricle. When it is very abundant, it raises the upper wall of the ventricle, and, on pressing gently with the finger, this wall presents a manifest fluctuation. In such case there can be no doubt but that the accumulation of serum in the cerebral cavities is a morbid phenomenon. We seldom find any perceptible differ- ence in the quantity of fluid contained in each ventricle. When- ever this quantity was very considerable, we have found the septum lucidum and the fornix very much softened. In some cases we have seen the two laminae of the septum lucidum separated by serum, and the cavity of the fifth ventricle thus become accidentally quite manifest. Instead of limpid serum we occasionally meet in the ventricles a turbid liquid, in which are observed those flocculi, called albuminous, which constitute so frequent an anatomical character of pleuritis or peritonitis. In some of the cases which came before us, we have seen the ventricles filled with a collection of real pus, which, by reason no doubt of its greater weight, was found accumulated in great quantity, principally at the lower part of each lateral ventricle, or in the ancy- roid cavity. In most of the cases where pus was found within the lateral ven- tricles, some was also observed at the same time in some points of the sub-arachnoid cellular tissue surrounding the nervous centres. The membrane yielding these varied products, once presented to our view some finely injected vessels, which lined as a network the DISEASES OF THE ENCEPHALIC MEMBRANES. 67 inner surface of the parietes of the ventricles. In all the other cases, in those even where pus filled the ventricular cavities, no appreciable lesion appeared in the membranes lining their parietes. We do not, in fact, consider as an alteration of nutrition in this membrane, but as a product of morbid secretion, small granu- lations,* which are sometimes seen scattered on the inner surface of the ventricular parietes, a remarkable specimen of which we ob- served in. one of our cases. ARTICLE IIP. Lesions of the Pia Mater. These have been much more frequently observed than lesion of the two other membranes. The lesions which this membrane has presented are the following: 1. Infiltration of its tissue by a clear, colourless, transparent serum. Sometimes this serum forms but a thin layer interposed between the arachnoid and the cerebral substance; sometimes ac- cumulated in more considerable quantity beneath the arachnoid, it raises this membrane, and distends the cerebral anfractuosities. 2. Infiltration of the tissue of the pia mater by a turbid, milky liquid, and sometimes by real pus.f The latter has sometimes a remarkable consistence; it is as it were intimately combined with the cellulo-vascular tissue within which it is formed ; it is concrete like certain pseudo-membranes of the pleura or peritoneum. 3. A real state of scirrhous induration of the tissue of the pia mater. We once saw such a state; between the arachnoid and the circumvolutions of the cerebral hemispheres there was a layer of solid matter, of a bluish grey, from five to six lines thick. This layer existed over nearly the entire extent of the convexity of the two hemispheres. 4. Serous cystsj variable in size and number. These may, in proportion as they become developed, compress the cerebral sub- * This is a result of inflammation of the surface of certain parts becoming sca- brous, as if covered with fine sand ; this appearance takes place in different parts, and is frequently very manifest about the foramen of Munro, or the peduncles of Ihe pineal gland. — Bright, vol. ii., G92. — T. f This is an undoubted result of inflammatory action, filling the meshes of the pia mater with a semifluid substance of a colour much resembling pus; it is not effused upon the surface of the arachnoid, nor does it remain upon the sur- face of the brain ; but when the membranes are drawn off, it separates with them, leaving the convolutions quite exposed, and when an incision is made into the membranes, none of the yellow deposit escapes.— Bright, vol. ii., 674. — T. | These serous cysts appear to be placed between layers of serous membrane, or to be contained in adventitious membranes ; they vary from the size of a pea to that of an orange; they are of a most chronic character, often give no symp- toms by which their existence is even suspected, and are probably coeval with life, not only the brain, but the bony parietes being often moulded to their form. — Bright, vol. ii., 675. — T. 68 ANDRAL'S MEDICAL CLINIC. stance more and more, and thus become, in a way altogether me- chanical, the cause of different phenomena. 5. Cartilaginous, or osseous plates, which we have seen in one case cover, like a second arch, the anterior fourth of the convexity of one of the cerebral hemispheres. 6. Tubercles,sometimes few in number and scattered over a broad surface, sometimes numerous and collected together, and forming, by their union, homogeneous whitish, masses, which, on the one hand, compressed the arachnoid, through which they were seen, and which, on the other hand, sunk deep into the circumvolutions, the tissue of which they compressed. In one case, where these tubercles were thus collected, the pia mater had, at the same time, contracted such intimate adhesions with the cerebral substance, that the latter was detached in large portions along with the pia mater. It often happens that tuberculous matter is deposited between two circumvolutions, the interval between which it perfectly fills up. It then happens that the two portions of pia mater, covering each circumvolution, come to form strong adhesions to each other, and in such case, a cursory examination might incline us to think that it was in the parenchyma of the brain that the tubercular matter was deposited. 7. Adhesions. — These are formed between the portions of pia mater leaving the arachnoid in order to line the interior of an an- fractuosity. Then this anfractuosity completely disappears, and several circumvolutions are observed as it were soldered together; they are so firmly united that they cannot be separated unless by tearing them. In concluding this enumeration, let it be observed, that most of the lesions of which medical writers place the seat in the arachnoid, and which they consider as the anatomical characters of arachnitis, reside most frequently in the pia mater. In almost all the cases, for instance, where the convexity of the cerebral hemispheres was covered with a layer of serum or pus, this layer had its seat beneath the arachnoid; on passing the back of the scalpel over the latter membrane,, the morbid product is displaced, but not removed. Sometimes this product is so extensively connected with the cellulo-vascular tissue, interposed between the arachnoid and brain, that it cannot be displaced even by the process just now mentioned. Every time we found tuberculous matter deposited around the nervous centres, in their enveloping membranes, it was not the arachnoid that appeared to contain this product of morbid secretion ; it filled the meshes of the pia mater. We might say as much of the cartilaginous or bony concretions occasionally found in the form of grains, or plates, more or less extensive, around the substance of the brain or spinal marrow; here too it was the pia mater which appeared exclusively to be the seat of them, except in the case above noted, where these concretions were developed between the arachnoid and dura mater. In fine, it is in the pia mater also that we find those smnll bodies DISEASES OF THE ENCEPHALIC MEMBRANES. 69 commonly known under the name of Glandular Pacchioni, which, in some subjects, are found in great numbers towards the edge, which separates the upper part of the internal surface of each cerebral hemisphere, but the existence of which is far from being constant. We think, with several other persons, that these bodies, so impro- perly called glands, area morbid product formed in the pia mater, and that they should no more be considered as a condition of the normal state, than should those cellular bands in the pleura, which, in consequence of their great frequency, some ancient authors have considered to be a physiological product. In fact, these bands have been designated, in old anatomical writings, by the name of ligaments of the pleura. If we now come to consider simple redness, and the different degrees of injection which the membranes may present, we might stiil further confirm by our own observation what has been said by Chaussier and others; we should find that this redness, more or less bright, more or less extensive, has, ninety-nine times in a hundred, its exclusive seat in the pia mater, and lhat above the latter the arachnoid remains transparent and colourless. However, whilst we admit that in the diseases designated by the name of arachnitis, or more properly meningitis, anatomy discovers lesions in the pia mater much more frequently than in the arachnoid ; still, we should not assert, as some writers would do, that the arach- noid always remains unaffected.. If it is not yet clearly proved that it has been sometimes found either injected or thickened, at least it is certain that morbid products have been found in its cavity. We have adduced cases where there were effusions in the cavity of the arachnoid either of serum or of pus; we have cited others in which cellular adhesions, similar to those of the pleura, united the two reflections of the arachnoid to each other. The lesions which may exist in the pia mater, may occupy different parts of this membrane. They are found more frequently in the convexity of the cerebral hemispheres than in any other part. When traced over this convexity, we sometimes find them extended to the two hemispheres, sometimes they are confined to one. Thus, in several of our cases, we have seen the upper surface of only one hemisphere, of a more or less bright red colour, or covered with pus, while the other was pale and free from any trace of purulent infil- tration, or any other lesion. Frequently too, it is not the entire of the upper surface of one of the hemispheres that is the seat of this lesion (whether injections or any other). It may occupy but a more or less circumscribed portion of this surface ; and with respect to the different symptoms which may result, it is well to remark, that there are some eases, where there is found either simple redness, or purulent infiltration,, precisely limited: — 1st, To the anterior ex- tremity of one or other hemisphere. 2d, To its middle portion. 3d, To its posterior portion. 4th, To its lateral parts. The ante- rior part of the hemispheres has appeared to be the most frequent seat of the partial meningitis. 70 ANDRAL'S MEDICAL CLINIC. We remember to have seen some cases wherein a bright redness existed simultaneously over the entire anterior extremity of eacn hemisphere; everywhere else the pia mater remained pale. On the lower surface of the brain the same lesions presented themselves, but with more frequency, at least if we are to rely on what we have seen ourselves. There also the pia mater is seen dis- eased over a great extent of surface; sometimes, as in the convexity of the brain, some points only are found affected. In the latter case, the part where we have most frequently found purulent infil- tration, is that which is around and posterior to the commissure of the optic nerves. Some pus is also observed occasionally within the fissure of Sylvius. One of our cases presented to us the rather remarkable phenomenon of purulent infiltration, which existed only on one of the halves of the pons Varolii and medulla oblongata. The pia mater covering the cerebellum, appeared to us much more rarely affected than the pia mater of the brain. The pia mater of the spinal cord presents all the changes to be found in that of the encephalon ; but from our own experience, as well as that of others, we find that the pia mater enveloping the spinal cord is much less frequently diseased, than the pia mater enveloping the brain. According to our experience also in most of the cases wherein the pia mater surrounding the spinal cord has become the seat of purulent infiltration, this same infiltration is also found in the encephalic pia mater. On the contrary, nothing is more common than to find the latter considerably altered, whilst the other is perfectly sound. With respect to the relative frequency of the lesions of the dif- ferent parts of the encephalic pia mater itself, we find that the lesions of the pia mater of the convexity of the hemispheres, exist more frequently alone than in the lesions of the pia mater of the base. In most of the cases where we ascertained an alteration in the latter, we found it either in the ventricles, or on the convexity of the hemispheres. Diseases of the membrane lining the inner surface of the ventri- cles, have not appeared to us necessarily connected with diseases of the pia mater surrounding the brain, either at its base or convexity. We have accordingly adduced some cases in which the ventricles were filled with pus, or considerably distended by serum, without any appreciable lesion existing in the external pia mater, nor in the other parts of the arachnoid. All possible varieties of alteration of the membranes may exist without the cerebral substance itself participating in any way with these alterations. In most of the cases reported this substance was perfectly untouched. But at other times we found it changed to- gether with the meninges. Thus, in some cases where the inflam- mation was principally seated in the part of the meninges covering the convexity of the hemispheres, we, not rarely, find the grev sub- stance of the circumvolutions injected and softened ; this substance is then raised like a pulp, when we try to separate the pia mater DISEASES OF THE ENCEPHALIC MEMBRANES. 71 from it. Sometimes we find no morbid alteration at a greater dis- tance down, and sometimes the entire medullary substance of the hemispheres presents on each slice a great number of red points, which are the divided orifices of so many vessels gorged with blood. In some cases, where the sub-arachnoid cellular tissue contained a great quantity of serum, we were struck with the species of oede- ma, of which the cerebral substance was itself the seat. On slicing this substance, and pressing it between the fingers, a serous liquid was expressed from it similar to that infiltrating the pia mater.* Every time we found in the ventricles serum sufficient to distend them perceptibly^ so that their upper wall presented an evident fluctuation, we were struck with the great softening of the central white parts of the brain — namely, the septum lucidum and fornix. In one case which we have reported, and where the ventricles contained pus, anotherspecies of softening existed; it was seated in the most superficial part of the cerebral substance which forms on the outside of the wall of the lateral ventricles. In these different cases, the alteration of the nervous substance seems to be a simple complication of the lesion of the membranes. There are other cases, on the contrary, where it is the meningitis that complicates the affection of the parenchymatous substance. Thus, for instance, in certain cases of exclusive softening, which commence quite near the periphery of the brain, we find a partial meningitis, whose limits are marked by the limits of the cerebral softening. CHAPTER II. DISTURBANCES OP FUNCTION. These disturbances are of two kinds; some are referrible espe- cially to the functions of relation or animal life, and serve in a par- ticular manner to characterise the disease ; others relate to the organs of nutritive life, and though they may be less characteristic than the former, they are not however void of importance in establishing the diagnosis. We shall now pass them both in review. * This cerebral oedema is the only alteration we met in an individual, whose body we lately examined, and who, about fifty hours before death, had fallen sud- denly, deprived of consciousness and motion. He died with all the symptoms characterising a violent attack of apoplexy. This was serous apoplexy. 72 ANDRAL'S MEDICAL CLINIC. FIRST ARTICLE. DISTURBANCES IN THE FUNCTIONS OF RELATION. SECTION I. Lesions of Sensibility. These lesions have, as their seat, either the membranes themselves, or the different parts which receive nerves from the cerebro-spinal axis. Similar in this respect to the different fibro-serous membranes, the meninges make known most of their alterations by a greater or less exaltation of their sensibility, whence arises pain of head, which becomes one of the most important symptoms to be considered in the history of meningitis. We shall first set about determining what is the degree of frequency of this symptom, in diseases of the meninges. Out of twenty-eight cases of affections of the cerebral meninges which we have reported, we find sixteen in which the headache existed, and twelve in which this symptom was not observed; but in these twelve, there was one (case 5) in which the patient was not minutely watched, and another (case 11) in which the delirium hav- ing existed from the commencement, the pain of head could not be complained of by the patient. In the sixteenth case, in which the pain did exist, the alterations discovered in the post-mortem were as follow: — In two of these cases (cases 1, 2) the patients presented after death tumours developed primarily in the dura mater, which had compressed the nervous substance in contact with them. In two other cases (cases 3, 4) an effusion of blood existed in the great cavity of the arachnoid. In two subjects (cases 18, 21) no other alteration was observed but considerable effusion of limpid serum in the cerebral ventricles. Three other subjects (cases 6, 7, 9) presented nothing but redness of the meninges. Another (case 8) presented pseudo-membranous concretions depo- sited within the great arachnoid cavity. In five post-mortem examinations (cases 10, 15,22, 24, 26) we found the pia mater, whether of the convexity, or of the base, infil- trated with pus. On one of these five (case 24) there were also found cellular adhesions intimately connecting together the two reflections of the arachnoid covering the convexity of the brain.— This individual had been all his life tormented with headache. In only one case (case 16) we found the ventricles filled with purulent fluid. From these facts we are warranted in concluding that the pain accompanying diseases of the meninges, may exist with diseases of DISEASES OF THE ENCEPHALIC MEMBRANES. 73 these membranes widely differing from each other both in their nature and their seat. Let us now inquire what lesions were found in'the membranes in the twelve patients who complained not of headache. In two of them (cases 10 and 16), the pia mater was infiltrated with pus, either the portion of it extended over the convexity of the cerebral hemispheres (case 10), or that covering the base of the brain (case 16). A sero-purulent liquid filled the ventricles in the subject of case 19. From these facts it follows, that the diseases of the membranes, during which no headache was observed, differed neither in their nature nor in their seat from those in which pain of head was one of the symptoms. The following table will show the greater or less frequency of the headache in these different cases : — Nature of the Changes. Headache. None. Accidental productions developed in the dura mater ....2.0 Effusion of blood into the great cavity of the arachnoid ....2.0 Redness of the membranes.............3.0 False membranes in the cavity of the arachnoid......4.0 Purulent infiltration of the pia mater..........5.2 Pus effused into the lateral ventricles..........1.1 Serous effusion into the pia mater externally, and into the ventricles 2 . 6 Chronic thickening of the meninges..........0.1 Out of sixty-two cases of acute inflammation of the meninges, free from any complication, described in the work of MM. Parent du Chatelet and Martinet on Arachnitis, there were fifty in which pain of head is mentioned as a predominant symptom. Of these fifty, some were cases of meningitis of the convexity, and the others me- ningitis of the base or ventricles. Of fourteen cases of acute menin- gitis free from complication, published by Dance, there were twelve in whom this symptom was observed. In the numerous cases published by Dr. Charpentier, of Valenciennes, in his work on Hydrocephalus Acutus, pain of head was noted as a more or less pre- dominant phenomenon of the disease. From this summary of the fqcts it follows that, in the great majority of cases, pain of head is a symptom of acute and chronic diseases of the meninges, and that it may accompany the most varied lesions of these membranes, either injection of their tissue, or the formation of membranous concretions on the free surface of the arachnoid, or purulent infiltration of the pia mater, or an effusion of pus into the ventricles, or a considerable accumulation of serum within these same ventricles. Can this headache serve to distinguish an inflammation of the meninges, and is it not also found in other diseases, which, though existing without the brain, may still give rise to several of the symp- toms which characterise acute meningitis? To the latter, acute inflammations of the digestive tube, in particular, may be referred. Out of forty-five individuals affected with inflammation of the diges- tive tube, whether follicular or simply erythematous, whose autopsy is detailed in another part of this work, twenty-one complained of 7 74 ANDRAL'S MEDICAL CLINIC. greater or less pain of head ; in the remaining twenty-four this symptom was not noted ; but among the latter there were seven, the precise history of whose state could not be satisfactorily ascertained. Out of thirty-one cases, whose history is described in the work of MM. Petit and Series on Entero-mesenteric Fever, twenty-one complained of pain of head. Among thirty-six patients mentioned in Professor Bouillaud's work on fevers, headache was observed in twenty-eight. Among fifty cases reported by M. Louis, in his work on Typhoid Fever, forty-four were affected with headache. From these cases, and several others published by M. Trousseau and M. Dance (in all of which the only lesion found was in the digestive tube), it clearly follows that pain of head is a symptom observed in other instances than those wherein the nervous centres are primarily and idiopathically affected; consequently it cannot be given as a proof of the existence of a meningeal affection. Presenting itself at the outset of several febrile affections, it indicates no doubt a disturb- ance of the innervation; but it no more established the proof of a real meningitis, than those pains of the limbs do, which are so com- mon in such cases. Is it not again to these pains, which are alto- gether nervous, and which are not connected with an inflammatory state of the organs in whose vicinity they are felt, that we should attribute several of the epigastralgia so frequent at the commence- ment of febrile diseases, and which we think are too often and too lightly attributed to a gastritis? Still, pain of head, though joined to a crowd of different affections, may present in cases of meningitis, certain distinctive characters, indicating its connexion with an inflammation of the membranes of the brain. To this matter we shall now direct our attention, considering this pain of head with respect to its seat, its nature, its intensity, and duration, the time of its appearance, and its connexions with the other symptoms. We have already seen that the headache is observed with equal frequency, whatever be the seat of the meningitis. We shall now inquire whether the seat of this pain of head varies with that of the affection, and whether it is possible to determine exactly the point where the meninges are affected, from the part where the pain of head is felt. On reviewing our sixteen cases where there was headache, we find that in five of them the seat of the pain of head was not pointed out, or that it was stated as affecting the entire head. In the eleven other cases, it was limited to a part of ihe cranium, and was often circumscribed very exactly to that part. Of these eleven cases of headache thus circumscribed, there are six in which the seat of the lesion of the meninges is very precisely indicated by the seat of the pain. In the five other cases, where, as in those already considered, the pain of head was circumscribed, we find no connexion between the seat of the pain and that of the lesion. With respect to the five cases in which we no longer find the pain of head circumscribed, there is but one of them in which the lesion of the membranes was circumscribed to one point. In the four other cases, the affection of the membranes was much more general; it existed over the entire convexity of the hemispheres in DISEASES OF THE ENCEPHALIC MEMBRANES. 75 cases 3 and 11; the serous membrane of the ventricles was specially affected in case 20 ; and, in fine, the entire of the membrane was affected in case 24. From these facts we may conclude, that though in some cases the seat of the lesion of the membranes may be indicated by that of the pain of head, it is not always so. We have seen, in fact, some cases in which the meningitis is either much more extensive or much more limited than the seat of the headache seemed to announce. Oftentimes also the pain manifests itself at a distance from the place where the membranes are affected. Thus we have seen a simple frontal pain of head coincide sometimes with meningitis of the base, sometimes with meningitis of the ventricles. This assertion of ours is corroborated by very many cases contained in the work of MM. Parent and Martinet, as also in that of M. Dance on the acute hydro- cephalus of adults, in which there is by no means a constant con- nexion between the seat of the pain and that of the lesion. If we now seek what is the seat of the headache in severe fevers, we shall find that, in the great majority of cases, the pain is frontal or sub-orbital; that in some it is more particularly felt either at the temples, the sinciput or the occiput; and that in some cases the patients cannot point out the precise seat. There are then some traits of resemblance, with respect to seat, between the headache which is the symptom of a meningitis, and that which exists in continued fever. However, we do not see in the latter case, as in the former, the headache confined to certain points of the head. The intensity of the headache appears to merit consider- able attention, when it may be an object to convert this symptom into a sign. The pain ofhead which accompanies severe fevers is most frequently not known by the physician, unless when he ques- tions the patient on the subject, the latter giving but a mere second- ary attention to it. In very many cases of meningitis, on the con- trary, it is the patient who first mentions the pain of head; and until he has become either delirious or comatose, this pain is to him one of the predominant phenomena of his disorder; it sometimes forces him even to scream aloud. It has not been found that the different degrees of the intensity of the headache depended either on the nature of the lesions of the membranes, or on their seat. We have found it as acute in cases where there was but simple injection of the pia mater, as in those where the pia mater was infiltrated with pus, or where a false membrane covered the arachnoid. With respect to the seat of the lesions, we find that, in cases where the headache was most intense, some related to meningitis of the convexity of the hemispheres, others to meningitis of the base of those hemispheres, others to inflammation of the entire membranes surrounding the nervous centres, others, again, to effusions of pus or serum into the ventricles. Between these cases, and those where the pain ofhead waseither much weaker,or none at all, wedonot find any difference with respect to the lesions; and in order to explain so many varieties, we are always obliged to admit individual disposi- 76 ANDRAL'S MEDICAL CLINIC. tions which, with lesions apparently identical, produce, according to the subjects affected, phenomena of the most different kind. The nature, also, of the pain felt by patients attacked with menin- gitis is not the same in all. Some think ihat there is an enormous weight on their skull ; some complain of violent lancinating pain, either continued, or returning at intervals; several fancy that a tight band compresses their forehead ; some say that their head is squeezed, as it were, in a vice. All motion applied to the head, or even to the other parts of the body, is oftentimes intolerable. We have seen some patients whose headache was increased by slight pressure made on the integuments of the cranium. We never saw, on the contrary, this pressure diminish the headache, as so often hap- pens in the cases of headache called nervous. Most frequently, how- ever, it shows itself, from the commencement, sometimes dull at first, and gradually becoming intense; sometimes, on the contrary, attaining at once its maximum of severity. In several cases of our own, in very many published by MM. Parent and Martinet, and in nearly all those of M. Dance, the pain of head showed itself from the very commence- ment. The cases in which headache marks the commencement of the disease seem divisible into two series, according as the headache develops itself singly, without any other morbid phenomena accom- panying it, or according as its appearance coincides with that of other symptoms. The first series includes the most numerous cases. The time during which the headache continues, the only appreciable morbid phenomenon, may vary from some hours to several days. When this headache thus precedes the other symptoms, there are some cases in which it seems to have nothing serious in it. It sometimes resembles mere rheumatic pain; sometimes it might be taken for neuralgia. There are some individuals who, for some time, seemed to have merely a megrim more or less violent; the mistake was easily fallen into in those cases where, a little after the appearance of the headache, vomiting supervened. The second series includes those in which the headache, still presenting itself at the commencement, is accompanied, from the moment of its appearance, by other symptoms, whether of mere febrile commotion, or of differ- ent disturbances of innervation. There are some rare cases in which the pain of head continues with great intensity during the entire disease; but most frequently there are developed on the part of the nervous systems more severe symptoms, which soon prevent it from being perceived or complained of by the patient. It may then be laid down that the pain ofhead generally exists only during the first period of meningitis. It is very uncommon to see it come on after this period. Headache is almost the only modification of sensibility observed in the ordinary cases of meningitis. In some few of the cases reported by us the cutaneous sensibility was rendered rather obtuse; but it may be remarked, that in one of them the brain itself was the seat of considerable pressure made by a tumour deve- loped in the dura mater. There was one case, "also, where the sensibility was very much exalted. From several cases published DISEASES OF THE ENCEPHALIC MEMBRANES. 77 by MM. Parent and Martinet, and also by M. Dance, we feel war- ranted in laying it down, that in the meningitis of adults, modifica- tions observed in the cutaneous sensibility may be considered as mere exceptions; when they do exist, they are to be referred to a peculiar disposition in the subject, and not to any specific lesion. It is but rarely that pains of any importance are observed in other parts of the body besides the cranium. If we compare, with respect to their nature and their frequency, the lesions of general sensibility observed in cases of acute meningitis, with those seen in cases of typhoid fever, we shall find that in both these lesions scarcely differ either as to their nature or their frequency; so that their existence cannot serve to establish the diagnosis between the acute meningitis and severe cases of fever. We shall now terminate this consideration of the modifications of sensibility in meningitis, by inquiring in what manner the organs of the senses are disturbed in this disease, particularly those of sight and hearing. The modifications in the organ of sight were, for a long time, noted by pathologists as capa- ble of serving to characterise certain acute or chronic affections of the brain. These modifications may be classed under the three following heads:— 1st. Modifications of the motions of the globe of the eye: 2d. Modifications in the state of the pupil: 3d. Modifi- cations of vision itself. The motions of the eye may be altered in several ways : sometimes they are irregular, and, as it were, convul- sive ; sometimes the globe is immoveable; sometimes there is stra- bismus of either one side or both. These different alterations in the movements of the eye cannot be referred to any specific lesion. They have been observed in adynamic and ataxic fevers without any appreciable lesion of the nervous centres. Strabismus, how- ever, when permanent, may be considered to possess more value as a sign of meningitis than the irregular movements of the globe of the eye, or its immobility. The state of the pupil is far from being always the same in the different cases of meningitis. Several phy- sicians consider that this opening, contracted and immoveable in the first stage of the disease, becomes dilated and immoveable, as soon as serous or purulent effusion has taken place, either around the brain or into the ventricles. This rule I do not conceive to be always exact; for with lesions precisely identical the pupils may present the most different appearance; and what is more, with lesions altogether dissimilar, these openings may present precisely the same appearance. This was also long since remarked by MM. Parent and Martinet. We find, in their work, cases of dilatation of the two pupils: first, with effusion into the two lateral ventricles; secondly, with effusion into only one ventricle; thirdly, with mere serous or purulent infiltration around the brain (at the convexity or base); fourthly, without any of these lesions. In four cases where dilatation affected only one pupil, the effusion existed in the two ventricles. In another case, where there was also but one pupil dilated, the effusion took place in only one ventricle, that of the side opposite to the dilated pupil. With respect to contraction of the 7* 7S ANDRAL'S MEDICAL CLINIC. pupils, MM. Parent and Martinet cite cases where this contraction coincided with an effusion into the ventricles, and other cases in which no effusion existed. M. Guersent, the writer of the article Meningitis in the Dictionnaire de Medecin (21 vol. edit.), admits dilatation as an habitual phenomenon only in the last stage of the disease; before that period, he says that the pupils are sometimes dilated, and sometimes contracted. The result of my own observation, as also of an attentive consid- eration of the cases published by others, is, that it would be vain to attempt to connect such or such a state of the pupil with any specific morbid alteration of the membranes. Abstracting from the nature and seat of the lesion affecting the membranes, the pupils in those different affections may present the different states which follow : — 1. The pupils may preserve their natural appearance. f Equal dilatation. | Unequal dilatation. 2. Dilatation of the pupils....^ Dilatation of only one. I Dilatation of one, and contraction (_ of the other. fEqual. 3. Contraction of the pupihJ ^"e^u.al- (^Of only one. 4. Alterations of contraction and dilatation of the pupils. But these different modifications of the pupils are also met in a number of cases, where neither the meninges nor the brain present any appreciable lesion after death. We have observed them with all their shades in individuals labouring under fever. Every one knows also how, even in a state of health, the condition of the pupil varies. And if the iris is thus subject in its movements to a thou- sand different influences — if it be under the dominion of many other modifications of the nervous centres, besides those which pathological anatomy shall ever be able to reveal to us, why place any great confidence in the signs to be deduced from the different states of the pupil in order to diagnose a meningitis? Vision itself is, as we have said, frequently disturbed in cases of meningeal affections. In some patient's it is entirely lost; in others it is perverted: thus diplopia has been observed in some cases; hallucinations have been also noted ; some persons cannot bear the rays^of light on the retina. None of these alterations, however, can be said to belong peculiarly to meningitis. Very few cases have been recorded by medical men, in which the faculty of hear- ing was affected in meningitis. Our second case affords an example oi deafness, in which, however, the entire lesion discovered after death was seated on the upper surface of one of the lobes of the cerebellum, and, consequently, at a considerable distance from the origin of the auditory nerves. There was then lesion of function without any appreciable lesion of the organ destined to perform it' Here, however, some portion of the encephalic mass was found DISEASES OF THE ENCEPHALIC MEMBRANES. 79 morbidly changed; whilst, in cases of typhoid fever, deafness has been observed, where the examination after death shows this mass and its envelopes to be in the healthiest state possible, at least to all appearance. The more we study the different alterations of sensibility presented by individuals attacked by meningitis, the more satisfied we are that none of these alterations are constant, none of them necessarily con- nected with such or such aformof meningitis,and that disturbance of function is much less dependent on the membrane so affected, than on the brain itself. It is this organ that produces these disturbances, and consequently they must vary in the individual cases, according as the brain participates in, and sympathises with, the irritation of its membranes. In this way also, may be explained the infinite variability of the symptoms of pericarditis ; for here too, the deter- mining cause of the symptoms is not in the pericardium, but in the heart itself. What you see on the dead body cannot always inform you what took place during life, and pathological anatomy does not certainly tell us all that is to be known with respect either to the nature, seat, or treatment of disease.* Lesions of motion. — Lesions of motion are more frequent in meningeal affections than those of sensation, but they are not more constant than the latter, and they are entirely wanting in cases where after death the same anatomical changes are found, as in the cases where these lesions have existed. Lesions of motion observed in affections of the meninges, may be divided into two great classes; in the one, the motions continue, but they are performed in a disor- derly way; in the other, the motions no longer exist. The first class comprises the different spasms, which are sometimes clonic, sometimes tonic. To clonic spasms we shall refer the disturbances of motion, which have been all noted in the different cases published on diseases of the meninges. Some persons present merely a state of general agi- tation; they are constantly in motion, and rest seems to them in- supportable ; they are incessantly anxious to change their position. In others, this agitation is confined to some particular part of the body; some patients are constantly moving their arms or legs; in some the trunk is alternately raised and depressed ; some constantly * When either the arachnoid or pia mater, which closely invest the brain, are extensively inflamed, the function of this organ becomes inevitably disturbed by sympathetic irritation, without its parenchyma necessarily partaking of the in- flammation, or if the inflammation extend to the parenchyma, it is mostly confined to the superficial layer of the cortical substances. This is exactly the manner in which the functions of the lungs and intestines are disturbed in pleurisy, or peri- tonitis. Hence, in arachnitis or meningitis, besides headache and intense.fever, we have an increase of the general sensibility, preternatural acuteness of the ex- ternal senses, violent delirium and convulsions, and finally collapse, coma, and death. Extensive inflammation of the hemispheres of the brain will be charac- terised by a nearly similar train of symptoms. In the great majority of cases, the two diseases give rise to each other, and are thus combined ; it is then extremely difficult, if not impossible, to discriminate between them. Cyclop, of Med., vol. i. p. 284___T, SO ANDUAL'S MEDICAL CLINIC. move the head from right to left, and from left to right. In these cases it is the will, though irregular, that produces the motion; there are cases, however, where the motions are involuntary; thus, in some patients, the muscles which terminate at the flexor tendons of the fingers, are agitated by violent contractions; hence subsultus tendinum ; several present, as a prominent symptom, a tremor which is sometimes general, and sometimes partial. Convulsions, properly so called, are among the most common phenomena accom- panying acute meningitis. These are sometimes, though very rarely, general. When partial, they are sometimes confined to the same part; at other times they affect different parts of the body suc- cessively. The parts most usually affected with convulsive motions in meningitis are, the globes of the eyes, the eyelids, the face, the lips, and finally the extremities. Tonic spasms, as they are called, are not less frequent than clonic, in the disease now under consider- ation. Thus permanent flexion of the fore-arm on the arm is often observed. Retroversion of the head, its inclination to the right or left, are sometimes observed in cases of meningitis, as also tetanic rigidity of the neck, trunk, or extremities, trismus, &c. Under the second class, in which motion is diminished, or alto- gether destroyed, may be reckoned those numerous varieties of paralysis observed in meningitis. This paralysis may affect the muscles of the eye, of the eyelids, face, lips," or limbs: either one, or several of these, may be deprived of motion. In these different parts the paralysis may be established either slowly, or as instanta- neously as the loss of motion succeeding cerebral hemorrhage. The paralysis may supervene from the commencement, or succeed one of the forms of spasms already mentioned ; it may alternate with these spasms; it may, in fine, co-exist with them, and we have witnessed more than once one of the upper extremities completely deprived of motion, whilst the other was more or less violently con- vulsed. There are also some cases in which the paralysis appears and disappears by turns; a phenomenon which will not surprise us, when we have seen, that in meningitis paralysis can exist only when there is compression of the brain. Simple hyperaemia of the pia mater, slight purulent infiltration of this membrane, are capable of producing it, or, to speak more accurately, are capable of producing in the brain that modification, inappreciable after death, which gives rise to it. After having considered in a manner purely noso- logical the different lesions of motion affecting those attacked with meningitis, we shall now try to establish some relations between these lesions, and the different changes found in the meninges after death. For this purpose we shall pass in review each of the dis- turbances of locomotive action already alluded to, first mentioning the cases only, where such disturbance existed singly at the last period of life. 1st. With respect to general agitation, none of our cases presented this symptom single. MM. Parent and Mar- tinet mention one case of it, in which the pia mater extended over the upper surface of the brain and cerebellum was infiltrated with pus. In another case mentioned by the same authors, in which this DISEASES OF THE ENCEPHALIC MEMBRANES. §1 lesion was observed, the meninges extended over the convexity of the left hemisphere of the brain were found red and thickened. 2d. Partial Agitation. We have not met one instance of this symptom uncombined with other lesions of motion. MM. Parent and Martinet mention a case in which there was observed a con- tinual balancing of the head to the right and left: this occurred the day before the patient died. The membranes covering the upper surface of the cerebrum and cerebellum were opaque, very red, and thickened. The tissue of the cerebrum, cerebellum, and spinal cord were remarkably dense. These same writers mention a case in which there was a continual moving of the lower jaw, similar to that of mastication. In this the pia mater of the con- vexity was infiltrated with pus. 3d. Subsultus tendinum. Neither has any case occurred to us in which this symptom presented itself singly. MM. Parent and Martinet, however, record four cases, in which it was the only disturbance of the locomotive functions. In one of these cases the meninges were red and thickened nearly throughout their entire extent. In the three others they were infil- trated with pus, either at the convexity, or towards the base; and in two of these three cases, the ventricles contained either a serous or a purulent liquid, with a granulated state of the membrane lining their parietes. 4th. Trembling of the limbs. We have not met any case of this occurring singly: but very few cases of it have been mentioned by others ; and where it did occur, no particular morbid change was discovered after death on which it could appear to de- pend. 5th. Convulsive movements. These are observed princi- pally in children. Five instances have been recorded in the work of MM. Parent and Martinet of their occurring in adults—in four of these there were convulsive movements of the eyelids, face, lower jaw, and extremities. In three of these four there was found purulent infiltration of the meninges of the convexity of the hemi- spheres; the fourth presented a membranous concretion, extended over the right hemisphere, and two ounces of serum in the right lateral ventricle. 6th. Grinding of the teeth. We have no account of this phenomenon having occurred singly in cases of meningitis. 7th. Permanent flexion (contracture) of the limbs. In the one case in which this was observed, we found considerable redness of the pia mater extended over the convexity of the left hemisphere of the brain, with injection of the grey substance of the circumvo- lutions of this side. In the case of a young girl mentioned by Parent and Martinet, who, during the five days previous to her death, presented permanent flexion of the two arms, there was found general inflammation of the arachnoid of the convexity. The meninges at the base were thickened, and a small quantity of pus infiltrated them towards the cerebellum. The ventricles were filled by a turbid serum. 8th. Tetanic rigidity. In a considerable number of cases where the prevailing phenomena are rigidity of the limbs, tetanic shocks of different parts of the body, tetanic curving of the trunk to the right or left, trismus, permanent retroversion of 82 ANDRAL'S MEDICAL CLINIC. the head, the lesions found after death do not differ in their nature from those just mentioned. Thus we observe different parts of the pia mater more or less injected, purulent infiltration of this mem- brane, serous or purulent effusions into the ventricles. In nineteen cases in which retroversion of the head was observed, this phenomenon coincided once with a lesion of the meninges of the convexity and base; twice with lesion of the meninges of the convexity, base, and that of the ventricles; three times with simple lesion of the meninges of the convexity, three times with lesion of the ventricular membrane, five times with lesion of the meninges of the base, and five times with lesion of the meninges of the base and ventricles. In fifteen cases where tetanic rigidity was one of the prevailing phenomena, whether general, or limited to some part, as to the neck, trunk, extremities, jaw, the lesions, with respect to their seat, were as follow : — Lesions of the meninges of the convexity ... three times. of the base - three times. of the ventricles ... three times. of the base and ventricles - four times. of the entire meninges - - twice. 9th. Paralysis. In the fifteen cases of hemiplegia already men- tioned, the following alterations were seen: in four the brain was compressed by accidental productions developed in the meninges, which compression constantly occured on the side opposite to that of the hemiplegia, and was made from above downwards. In five of these cases the compression was confined to one of the cerebral hemispheres; in one only (case 2) a tumour appertaining to the dura mater had compressed and wasted one of the lobes of the cere- bellum. In this last case also the paralysis was crossed, just as in those cases where the lesion was seated in the cerebral hemispheres, and nothing else was observed but simple hemiplegia, without any other modification of motility. However, before the hemiplegia was established, convulsive movements had taken place in the arm of the side opposite to that of the lesion of the cerebellum ; after- wards this limb ceased to have the power of motion ; and subse- quently the paralysis extended to the lower extremity of the same side. In the subject of our first case, the hemiplegia was established gradually without being preceded by any convulsive movement. There was in this case pressure made on one of the cerebral hemi- spheres by a fibrous vegetation of the dura mater. In our fourth case the extremities of the right side were both gradually paralysed; the forearm continued a considerable time flexed on the arm but this flexion ceased at a subsequent period. Blood was found effused on the left side between the arachnoid and dura mater. In one of our cases, where a serous cyst, developed in the pia mater of the convexity, had perceptibly depressed the circumvolutions, the patient had a hemiplegia of very long standing, with atrophy of the para- lysed limbs. In six other cases, observed partly by ourselves and DISEASES OF THE ENCEPHALIC MEMBRANES. §3 some by MM. Parent and Martinet, this hemiplegia was seen to coincide with the presence of a thick layer of pus which filled the pia mater of the convexity of the cerebral hemispheres. Of these six cases there were three in which, though there was hemiplegia, an equal quantity of pus was effused over the two hemi- spheres, and three others, in which the pus was collected only in the hemisphere of the side opposite to that where the paralysis took place. At first sight, the proportion here seems equal, but a more attentive examination will alter it entirely ; for, in one case, at the same time that the pia mater of the convexity of the two hemispheres was infiltrated with pus, the substance of the brain (the left hemi- sphere), on the level of, and external to, the ancyroid cavity, con- tained a tubercle, which may be fairly consideredjto have caused the hemiplegia, more particularly as the latter affected the right side, and had come on progressively. In another of these cases, in addition to the purulent infiltration of the entire pia mater,on open- ing the body, the inner table of the frontal bone was found a little depressed, and making slight pressure on the brain. Besides, the effusion of pus, which had taken place over th two hemispheres, extended to the base of the cranium on the side opposite to that where the paralysis had taken place. There remains then but one case in which the paralysis having occurred on the left side, the entire pia mater was found infiltrated with pus, without any other complication, and even in this case, it was said, that towards the base the pus was more particularly accumulated on the right side. Thus in these six cases of hemiplegia, with effusion of pus around the encephalic mass, there is not, in reality, one, in which the lesion was not greater on the side opposite to that of the paralysis. Of these fifteen cases of hemiplegia already mentioned, there re- main five in which the principal lesion existed within the ventricles, and of these five there were two, in which both the lateral ventri- cles were equally affected; in the three others, the only, or princi- pal lesion, existed in the ventricle opposite to the side of the para- lysis. In one of the above two, each lateral ventricle contained four ounces of limpid serum; the hemiplegia was on the right side, and seemed to have existed previous to the effusion. In one of the above five cases, the ventricles were distended by a considerable quantity of serum ; there was also at the base of the brain a pseudo- membranous exudation, and the central white parts were softened. What was remarkable in this case is, that the paralysis which ex- isted on the left side was but transient. The patient, at first, pre- sented some rigidity of the forearm ; slight retroversion of the head; convulsive movements of the eyes and strabismus; then the right commissure of the lips was dragged; the extremities on the left side fell into a state of paralytic relaxation, whilst those of the right side retained motion and sensation ; subsequently the mouth became straight, and the left extremities recovered their power of motion. In the fifth of these cases reported by MM. Parent and Martinet, and which they borrowed from Morgagni, the left ventricle was filled with pus, without there existing, either in the brain or its ap- S4 ANDRAL'S MEDICAL CLINIC. pendages, any other appreciable lesion. During life, the power of motion was destroyed over the right side of the body. In a case reported by M. Dance, serum was found in the two ventricles; but in the right there were but three ounces, and in the left five: the membrane lining the parietes of these ventricles was also perceptibly thickened. A paralysis, which went on gradually increasing, affected the extremities of the right side, and the face on the same side. The extremities of the left side presented some tetanic twitches. The nature of the phenomena here seems to have been determined by the inequality of pressure made on each cere- bral hemisphere, by the liquid contained in the ventricle. — In- stead of hemiplegia, some cases occur in which there is paralysis of only one limb. Thus, in one case where the pia mater, traversed by tubercular granulations, was infiltrated with serum towards the convexity of the brain, the right arm, as well as the right side of the face, were the only parts affected with paralysis. In case '■>">, where pus infiltrated the pia mater of the convexity, and filled the ventricles, we witnessed, on the one hand, paralysis of the right arm, and on the other hand, paralysis of the left eyelid, which was depressed over the eye; as also of the left cheek, which became passively distended at each expiration. In these two cases the brain was exposed, on both sides, to equal pressure; yet, why do we find effects so different on the two sides of the body? MM. Parent and Martinet relate a case where there were observed alter- nately, and within a short space of time, at first convulsive move- ments of the left arm, then paralysis of the right arm, then con- vulsions in this same right arm; and at the same time that these convulsions exist, the right side of the face was struck with para- lysis. What do we find, however, on opening the body 1 Pus over the entire convexity of the brain only being more abundant on the right. In the numerous cases, where some parts, as one side of the lips, or one of the eyelids, are the only parts paralysed, we find lesion of the same nature and the same extent as in the preceding cases. The parts of the nervous centres which give origin to the nerves of the eyelids and lips, present no appreciable lesion, and the pia mater is found either injected or filled with pus, as in the cases where complete hemiplegia existed. We shall now consider those cases in which the loss of motion, instead of being confined to any particular part, is, on the contrary', general, and affects, either successively or simultaneously, the two sides of the body. In all the cases of this kind which have occur- red to us, when the paralysis of both sides came on before the final struggle, we found, on both sides of the brain, lesions correspond- ing to this symptom. The different facts which have now been analysed, with the view of discovering what are the lesions, which, in cases of meningitis, coincide with the different alterations in the power of motion lead us to a singular conclusion, namely, —that with similar lesions of structure in the dead body, the most varied disturbances in the DISEASES OF THE ENCEPHALIC MEMBRANES. 85 function of motion are found to coincide ; in the greater number of cases, whether there has been convulsion or paralysis, the structural lesion after death will be the same. Thus, beyond that lesion which the scalpel points out as having its seat in the membranes of the brain, there is, in the brain itself, a modification, not recognisable by the anatomists, which is produced to be sure by the lesion of the membrane, but which, variable in each individual, is the real cause of all the functional disturbances which are seen to supervene. The different disturbances in the function of motion now passed in review, may take place also in several other cases, where, the membranes being uninjured, the cerebral substance itself is altered. They may develop themselves in those diseases known under the name of fevers, the seat of which we are so often led by the symp- toms to place in the brain. In fevers, an in acute meningitis, we often observe subsultus tendinum, convulsive motions, oftentimes partial, very seldom general trismus, tetanic affections of the trunk or extremities, permanent flexion of these same extremities, rigidity and paralysis of them, as well as that of the eyelids and lips, trem- bling of certain muscles, grinding of the teeth. But in the great majority of cases, these phenomena are less frequent, less intense, and less durable. Their existence, however, proves that this same modification, produced in the brain by the irritation of the mem- branes, may also be produced in it under the influence of other causes, and that, without there being found, after death, any appre- ciable alteration either in its substance or in the membranes which envelop it.* * M. Lallemand speaks somewhat decidedly regarding the feasibility of dis- tinguishing arachnitis from inflammation of the substance of the brain by means of the symptoms connected with lesion of the functions of the muscular system ; after premising that these symptoms present themselves under two opposite forms, with increase or diminution of action, with phenomena of irritation or of prostra- tion, and having stated that both forms of action are common to arachnitis and encephalitis, he then says—"You see, by these case9, that the spasmodic con- tractions of the muscles may be produced by an arachnitis, and we shall see pre- sently that attacks of epilepsy, contractions of the limbs, convulsive movements, subsultus tendinum, are the ordinary symptoms of affections of this membrane. You must not, however, infer from this, that the arachnoid has a direct influence on the muscles. When this membrane is inflamed, the brain is irritated by the vicinity of the inflammation, its functions are exalted, and consequently those of the nervous system which are dependent on it, therefore also those of the muscu- lar system ; thence, convulsive movements, &c. ; but as the tissue of the brain is not touched, these spasmodic symptoms are neither accompanied nor followed by paralysis. Thus, though they are sometimes observed at the commencement of inflammations of the brain, they are not sufficient to characterise this disease. But you will remark, that at this period the brain is as yet only irritated as in cases of arachnitis, its tissue not being yet altered ; it is not surprising, therefore, that the symptoms should be the same. However, it would be possible even now to distinguish them by this means : when they are produced by the affection of the arachnoid, they usually manifest themselves on the two sides of the body, whilst, when they depend on inflammation of the brain, they most frequently affect only on one side. Besides, they cannot be confounded long ; for in the latter case they are soon accompanied by symptoms of paralysis, and very frequently even there is observed from the commencement the most singular mixture of 8 S6 ANDRAL'S MEDICAL CLINIC. ARTICLE III. Lesions of the Intellect. The intellectual faculties were found altered in the great majority of the cases which we have reported, as may be seen by referring to them. In fifty-four cases of acute meningitis affecting adults, reported by MM. Parent and Martinet, there were only two in which the intellect was not disturbed ; whence, we may lay it down that lesion of the intellect is a much more constant phenomenon in acute meningitis, than that either of sensation or motion. Such lesion may present itself under two different forms in this disease, either under the form of delirium or that of coma. The delirium may present the greatest varieties with respect to its nature; in some it is very violent, accompanied with loud cries, and a great development of muscular strength. In others, on the contrary, it is of a silent description, and the patients appear very much prostrated in strength. Sometimes one single idea engages the mind of tlve patient; sometimes ideas of the most heterogeneous description occupy his thoughts. In some, this disturbance of intellect attains its highest degree from the very commencement; in others it comes on gradually and insensibly. On reviewing, in each case, the numerous varieties of form which the delirium presented, we might arrive at this important conclusion ; — that no single one of these various forms characterises meningitis, that there is not one of them which may not be found in the different cerebral irritations which are purely sympathetic, and unaccom- paralysis and spasmodic phenomena." Lettre ii., p. 251 ; and at p. 277, he says: "To sum up, the affections of the brain, and those of the arachnoid by their in- fluence on the functions of the brain, manifest themselves externally by the lesion of the same functions, that is to say, by symptoms which are related to the per- ception of the impressions made by external agents, to intelligence, and to volun- tary motion. The symptoms of inflammation of the brain present two characters entirely opposite ; those of irritation, and those of collapse. On the one hand, exaltation of the intellectual faculties, headache, sensibility of the retina, con- traction of the pupil, pains of the limbs, continued or intermittent contraction of the muscles: on the other hand, diminution of intelligence, stupor, somnolence, deafness, loss of sight and of speech, paralysis of the muscles, insensibility of the skin. The former set of symptoms are also observed in inflammation of the arachnoid, and the second in apoplexy. But it is only in inflammation of the brain that they are found combined, because in the former case there is irritation of the brain without alteration of its tissue; in the second there is, from the first, alteration without irritation : it is only in inflammation of the brain that there can be successively irritation and disorganisation. When the paralysis precedes the spasmodic symptoms, it is, that the alteration of tissue precedes the inflam- mation; that is to say, there is from the first effusion of blood. Finally, when the spasmodic symptoms are wanting, the sfow and progressive course of the paralysis will easily render it distinguishable from that which ie produced by apoplexy. Thus then in inflammation of the arachnoid we have spasmodic symp- toms without paralysis ; in apoplexy, sudden paralysis without spasmodic syrnp. toms ,• in inflammation of the brain, spasmodic symptoms, slow and progressive pa- ralysis, unequal and intermitting course.,'> DISEASES OF THE ENCEPHALIC MEMBRANES. §? panied with any structural alteration of the membranes appreciable on the dead body. When once the delirium has developed itself, it may not cease presenting merely alternations of exacerbation and remission; it may also be only transitory. There are some patients in whom this disturbance of the intellectual faculties is but of very short dura- tion ; then, at the end of a period, more or less long, it returns; the intermissions become more and more short, and at last, the dis- turbance becomes continued. In some, the delirium commences only at night, and the clearness of the intellect during the day seems, at first, to exclude the idea of a meningitis altogether. In some, a delirium of several days' duration suddenly disappears a little before death, when the other symptoms become more aggra- vated. Wherefore, when it is attempted to distinguish the delirium produced by meningitis from the delirium produced by sympathetic irritation of the brain, it is wrong to lay it down that the latter only can be intermittent, as numerous cases prove, beyond all doubt, that delirium arising from meningitis may be accompanied with perfectly lucid intervals. The period of the disease at which the delirium appears, is far from being the same in every case. Very rarely this phenomenon marks the outset of the malady; so that, in the midst of health, when delirium does suddenly come on, it is not at all probable that it is dependent on meningitis. In the great majority of cases, pain of head precedes it; and oftentimes six, eight, twelve, and even fifteen and twenty days pass on between the period at which the pain of head presents itself, and that at which the intellect commences to be disturbed. Out of forty cases of acute meningitis which fell either under our own view, or under that of others, in which we were certain on the one side of the precise time of the invasion of the disease, and on the other hand of the moment at which the intellect began to be disturbed, we found the delirium to develop itself times. 1st day - 3 times. 7th day - 4 tii mes; 13th day - 4 2d - 1 8th - 6 14th - 1 3d - 3 9th - 2 15th - 2 4th - 3 10th - 0 16th - 1 5th - 3 11th - 0 20th - 2 •6th - 3 12th - 1 24th - 1 Since, with very few exceptions, delirium presented itself as a constant phenomenon in acute meningitis, we must conclude that it may be produced in this disease, whatever be the nature of the lesion of which the membranes are the seat. All the lesions, in fact, observed in our several individual cases, were accompanied with delirium. It is certainly curious to see a mere sanguineous congestion of the pia mater, even in cases where it is partial, a little pus infiltrating its meshes, produce the most serious disturbance in the intellects; whilst a much more deeply seated alteration of the brain, an extensive softening for instance, often exists without giving rise to the slightest disturbance of the intellectual faculties. Is it, as has been said, because the irritation of the membranes re- 88 ANDRAL'S MEDICAL CLINIC. acts principally on the most superficial parts of the cerebral circum- volution?, and that the intellect is chiefly seated there?* We shall next consider, whether for the production of delirium it is a matter of indifference what part of the meninges be affected. In this inquiry we can take into account those cases only in which the delirium continued to the end, single, and without being fol- lowed by coma. We have met but twenty-eight cases of this kind occurring either in our own experience, or recorded by others. In these twenty-eight cases, the lesion existed On the upper surface of the two cerebral hemispheres - - 14 times. On the upper surface of only one hemisphere - - - 15 On the upper surface of the two hemispheres, and at the base 3 On the upper surface of the two hemispheres, at the base, and in the ventricles ------ .-4 At the base alone --------0 In the ventricles alone •.....--2 Thus in these cases there are nineteen in which the lesion was limited to the convexity of the hemispheres, and only two in which the delirium persisted until death, without there being a lesion of the meninges extended over the upper surface of the brain. Instead of delirium, patients labouring under acute meningitis may present a state of coma, which sometimes exists from the com- mencement of the disease, and sometimes comes on only after delirium. This second case is much more frequent than the first, at least in adults. When a patient dies in the midst of a state of coma, the lesions found in the meninges differ neither in their nature nor seat from those found in cases where life is terminated in the midst of a state of delirium. But then are these lesions different as to their seat? To solve this question, we shall take a review of the facts as they have been observed. Out of sixty-one cases, in which death supervened in the midst of a comatose state, which existed either for several days with or * On the subject of delirium, as connected with arachnitis, Lallemand makes the following remarks : — " Delirium is in general regarded as a symptom of in- flammation of the brain ; its absence might induce one to doubt of the inflam- matory nature of softening of the brain. But it is, on the contrary, a stronger reason for this opinion ; it will be no difficult matter satisfactorily to prove that delirium is never observed in inflammations of the brain which are exempt from complication, that this symptom belongs specially to inflammations of the arach- noid, that persons have been led into error by the very numerous cases in which the affection of the arachnoid preceded that of the brain. I admit that it seemed natural to attribute the delirium to inflammation of the brain, rather than to that of the arachnoid; but still an error was committed. Do not, however, suppose that I would make the arachnoid the seat of the delirium ; every symptom is the alteration of a function, and cannot be produced but by the organ which executed this function ; butl have already said that the affections of the arachnoid influ- ence the functions of the brain in the same manner as the affections of the pleura influence the functions of the lung. It is impossible that the arachnoid should be inflamed without the surface of the brain in contact with it being also affected • but its tissue not being altered, there merely results from this vicinity an exalta- tion in its functions." — Lettre ii., p. 246. DISEASES OF THE ENCEPHALIC MEMBRANES. 89 without preceding delirium, or at least for twenty-four hours, we found the lesion to exist On the upper surface of the two cerebral hemispheres - - 11 times. On the upper surface of but one hemisphere ... 6 On the upper surface of the two hemispheres, and at the base 5 On the upper surface of the two hemispheres, and in the ventricles 13 On the upper surface of the two hemispheres, at their base, and in the ventricles --------- 8 In the lateral ventricles ------- 9 At the base of the brain ------- 4 Hence it follows that coma may come on at the different periods of acute meningitis, whatever be the part of the meninges affected. We cannot, therefore, lay it down with some authors that delirium appertains exclusively to meningitis of the convexity, and that coma is peculiar to meningitis of the base. We think that, whatever be its seat, meningeal inflammation may have the effect of deter- mining, in the brain at first a period of exciternent announced by delirium, then a period of collapse, either real or apparent, which is manifested by coma. In the great majority of cases which ter- minate in death these two periods exist. However, in some in- stances, the period of excitement continues beyond the usual time, and such persons die before the coma has supervened. In others, on the contrary, the signs of excitement are very transient, scarcely ever apparent, and the state of coma declares itself, without having been preceded by delirium, properly so called. There are, in fine, some cases in which the coma is the first symptom; individuals who a little before were in a good state of health, fall down sud- denly deprived of consciousness, sensation, and motion. Our 20th and 21st cases present examples of this apoplectic form of the dis- ease. In the two individuals who form the subject of them, nothing else was found but an enormous distension of the ventricles by limpid serum. Does this form, which differs from all the others, belong exclusively to acute dropsy of the ventricles ? It is possible that the mere effusion of serum around the brain, which infiltrates the pia mater, and suddenly compresses the nervous mass, may also produce this apoplectic form ; but in all the cases of this kind hitherto observed, the ventricles were the principal seat of the effu- sion. To the cases already cited, we might add another recently published by Dr. Martin Solon; it was that of an old man, seventy- six years of age, labouring under organic disease of the heart. The dropsy symptomatic of this affection had gradually disappeared, and the patient appeared to be doing very well. He got up one morning out of bed to go to the water closet — returned quickly to his room with his face much flushed, endeavoured to make towards his bed, v/hen he fell down suddenly,, and expired without uttering a word. On opening the body, the sinuses were found gorged with blood, the surface of the brain pale, the arachnoid transparent, not thickened, raised by a serous, limpid, colourless liquid, which infil- trated the pia mater, and might be estimated at about five or six 8* 90 ANDRAL'S MEDICAL CLINIC. ounces. The lateral ventricles were also found filled with a serum equally limpid and transparent; neither their parietes, nor the cen- tral white parts presented any softening. In the chest was disco- vered an organic affection of the heart, namely, dilatation of its cavities, a thinness of its walls, and a cartilaginous state of the tri- cuspid valve. Thus, then, in proportion to the greater or less rapidity with which a serous effusion takes place, whether simultaneously into the ventricles or around the brain, or solely within the ventricles, very different forms of disease may present themselves. If in a very short space of time, a very large quantity of serum has been exhaled by the arachnoid, the result may be a morbid state similar to that which is produced by a very large cerebral hemorrhage, in other words, apoplexy. This is serous apoplexy, an affection which we consider the moderns have been very wrong in erasing from their nosological systems.— (See case 20.) If the serum accumu- late somewhat less rapidly, either in the external pia mater, or in the ventricles, the symptoms are then observed to be such as ac- company every irritation of the meninges.— (See case 19.) If the accumulation of serum takes place slowly, there may result a third form, of which we have an example in case 21. Here the power of motion remains unimpaired, whilst the intellect becomes weak- ened only by degrees. To conclude: in those cases where the disturbance of the intel- lect depends on an affection of the meninges, the cause of this dis- turbance can no more be referred to any specific alteration, than that of motion or sensation can, and the diversity of the lesions of intelligence, as well as those of sensation and motion, can only be accounted for by referring it to the different susceptibility of the brain to impression. CHAPTER III. DISTURBANCES OF THE FUNCTIONS OF THE ORGANS OF NUTRITIVE LIFE. Several of these disturbances are very important to be con- sidered, when we wish to establish the diagnosis of meningitis, and to distinguish it from other diseases in which nearly the same func- tional disturbances of the brain are observed. On the part of the digestive organs, for instance, there appear in a great number of individuals attacked with acute meningitis very remarkable morbid phenomena, which supervene, but much more rarely in cases where the intestine is the seat of inflammation more or less intense. The circulation is also disturbed in certain cases in so particular a way that, by combining the signs furnished by it with the signs afforded by the disturbance of the cerebral functions, we may be able to at- tain with certainty the diagnosis of meningitis. i * DISEASES OF THE ENCEPHALIC MEMBRANES. 91 ARTICLE I. Lesions of the Functions of the Digestive Apparatus. In a considerable number of individuals attacked with meningitis, the digestive tube does not present during life any appreciable func- tional lesion. In others it is the seat of disturbances more or less severe; in this latter case, it is an object to inquire whether these disturbancesare merely the result of an abnormal influence exercised by the nervous centres on the digestive passages, or whether they are connected with an affection of these same passages, which af- fection has complicated the disease of the encephalic membranes. When the meningitis was not complicated with any other affec- tion, we found the tongue always to preserve its natural state ; it is broad, moist, free from any redness, and sometimes even paler than usual; most frequently it is covered with a light white coating. This was the result of the analysis of thirty-seven cases, in which the state of the tongue was carefully noted. Among these thirty- seven, there were twenty-four in whom the tongue preserved the state above mentioned during the entire course of the disease. Now of these twenty-four cases, sixteen of which came under our own observation, and the rest under that of M. Dance, we find there were fourteen in whom the stomach presented nothing unnatural after death, the remainder of the digestive canal also being per- fectly sound, with the exception of case 7th, where the lesion found was on the decline, and was connected with a disease, the symp- toms of which ceased to exist several days before death. — (See the remarks subjoined to this case.) — There remain ten then in which, the tongue having preserved its natural appearance till death, the stomach, however, did not appear to be in its physiological state. But the lesions presented by it were such as, under ordinary cir- cumstances, do not exercise any influence on the state of the tongue. We shall now consider the thirteen cases in which the tongue lost its natural appearance. It was then red, dry, cleft, brown, en- crusted or covered with a mucous coat, much thicker than the thin white coat already mentioned, which cannot, in our opinion, be con- sidered a morbid state of the tongue. Now of these thirteen cases there was not one which presented the gastric or intestinal mucous membrane entirely exempt from lesion. Sometimes this lesion was of a serious character, and of that class of lesion which usually co- incides with a modification in the state of the tongue; sometimes, on the contrary, the lesions found in the stomach were of a descrip- tion similar to that of the lesions which we have already seen to co- incide with a natural state of the tongue. It may be here remarked that acute inflammations of the bladder oftentimes modify very per- ceptibly the state of the tongue. — (See case 17.) In recapitulation, it may be asserted that every time when, in an 92 ANDRAL'S MEDICAL CLINIC. individual who has died of an affection of the meninges, we found on examination no morbid state either of the digestive or urinary passages, the tongue never lost for one instant its natural state; it also preserved it in several cases where the lesions found in the stomach were of the nature of those which most frequently do not modify the state of the tongue; and, in fine, the tongue has scarcely ever lost its physiological state, except in cases where the ne- cropsy pointed out disturbances which are known to coincide ordi- narily with a modification, more or less perceptible, of the state of the tongue. Every time then that, in a patient who exhibits several of the signs of encephalic irritation, the tongue shall be found red, dry, brown, &c, we shall be disposed to consider either that this ir- ritation is but the sympathic product of another disease, or else that the latter complicates it.* Thus among the numerous causes which may modify the state of the tongue, we must not consider inflam- mation of the meninges. But during its progress, or simultaneously with it, different morbid states may be developed, which may or may not be appreciated by morbid anatomy which may bring on with them a modification in the natu.ral state of the tongue. In most of the cases where meningitis was not complicated with any affection, the thirst did not seem to us to be very great. The loss of appetite oftentimes manifested itself at the onset of the dis- ease ; yet in some cases the appetite still remained, even when the intense headache, so frequently marking the commencement of the disease, already existed for several days. In some cases the epigastrium was the seat of pain sufficiently acute to be increased by pressure, and we have not seen in any of the cases where this pain existed, that there was a complication of gastritis. This pain in the epigastrium manifested itself in most cases at a period not far removed from the commencement of the malady. We never observed it to become very intense, nor is it to be compared in this respect to the pain of head. We are now come toone of the phenomena which best characterise certain cases of meningitis, we mean vomiting and nausea. Here, as in several other circumstances, the stomach is the seat of the phe- nomenon ; but its cause is elsewhere. Vomiting, or at least nausea, very frequently accompanies acute inflammation of the meninges: these phenomena show themselves almost always in the first stage of the disease, and often mark its commencement. Sometimes they, not being oftentimes repeated, attract but little attention; and after about twenty-four or thirty hours, they do not return. Some- times, on the contrary, they continue for several days, and'occa- sionally during the entire course of the disease. * As there is no rule without an exception, we may state here, that in some cases reported in the volume on Diseases of the Abdomen, where the prevailing symptoms were these of ataxic fever, the natural appearance of the tongue mi. ANATOXKnr. Professor Samuel D. Gross, M.D. NEW EDITION. ELEMENTS OF PATHOLOGICAL ANATOMY. By Prof. SAMUEL D. GROSS, M.D., Professor of Surgery in the Louisville Medical Institute, Ky. Late Professor of General Anatomy, Physiology, and Pathological Anatomy in the Medical Department of the Cincinnati College. Illustrated by 50 Coloured Plate figures, and 250 Engravings on Wood by the first artists. 1 super-royal 8vo. vol., extra sheep. *' It is a noble volume, both by its intrinsic merits, its pictorial illlustrations, and the entire mechanical execution."—Bull, of Med. Science. " That it will henceforth be regarded as a standard work, and introduced into the library of every physician of the interior who aims either to educate his pupils thoroughly, or keep himself informed on the improvements of this essential branch of medical and surgical science, we cannot doubt."—West. Joarn. of Me/Land Surg. '• This second edition is from the press of Barringlon and Haswell, in a mammoth 8vo. of 8-2 pases illustrated by very accurate and very elegant drawings, some of which are colored to vie with nature ia delicacy of tints."—Bost. Med. and Surg. Journ. " We regard it as one of the most valuable worl;s ever issued from the American press, and it does great honor alike to the author, and the country of his birth."—N. Y. Journ. of Med. " We have spoken in high terms of it because it possesses real and desirable excellencies."—Phila, Med. Exam. " We can strongly recommend his ' Elements of Pathological Anatomy' to the attention of the pathological inquirer."—Amer. Med. Lib.and Intel. DISSECTOR'S GUIDE. Edward J. Chaisty, M.D. THE LONDON DISSECTOR. OR GUIDE TO ANATOMY: jFor tlje ZXsz of Students. Comprising a Description of the JMuscles, Vessels, JVerves, Lymphatics, and Viscera of the Human Body, as they appear on Dissection: With Directions for their Demonstration. By EDWARD J. CHAISTY, M.D. REVISED AKD CORRECTED. 1 vol. 12mo. muslin. " Although there are several of these dissecting-room companions, there is not one in the whole catalogue that wears better, from its intrinsic value, than the old London Dissector. 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" Its chief excellency, however, is its mode of reference, in which it differs from the usual method of numbering the dffferent vessels, and referring to their numbers in the accompanying explanation-"—Med. Exam. "The drawings are veKy distinct and weH coloured- The idea of this work was a happy one, and, we trust, for the benefit of students, that the author will extend it to the veins, nerves, &c."—Amer. Journ. of Med. Sciences. " As a help to lhe Medical Student, we can cheerfully recommend it."— Western Lancet- Extract from a Letter of Prof. Webster, dated Geneva, Oct. 13lA, 1845. "I have examined it, and think it a very useful work, so much so that I shall re- commend it to my class, and adopt the arrangement in my description of that system." " We recommend every Student of Medicine to purchase a copy of this work, as a labor-saving machine, admirably adapted to refresh the memory, with knowledge gained by lectures, dissections, and the reading of larger works."—N. Y. Jour. Med. " This work is from the pen of a Philadelphia anatomist, whose familiar knowledge of the subject has been aided by the press, the result of which is a volume of great beauty and excellence. Its fine execution commends it to the student of Anatomy. It requires no other recommendations."—West. Journ. of Med. and Surg. OUTLrNES OF THE NERVES, With short Descriptions: Designed for the Use of Medical Students. With Engravings. Br JOHN NEILL, M.D., Demonstrator of Anatomy in the University of Pennsylvania ; Physician to Wills's Hospital; Lecturer on Anatomy; Member of the Philadelphia Medical Society, etc., etc. "This volume is as beautiful as it is useful, — one in which both author and pub-. Ushers have united their efforts for the especial benefit of the student, to whom a more acceptable work could not be offered, for facilitating an adequate acquaintance with the elements of neurology. Like (hat on the arteries, it has the distinctive recom- mendation of the names being affixed to the trunks and ramifications of the'nerves, and in this way, of saving a deal of trouble and time, and of impressing them more firmly on the memory. " The engravings are in the best style, and the paper and type correspond ; and yet, notwithstanding these evidences of what might seem luxurious indulgence in tasteful decoration, the volume is sold at a price which would be thought extremely low for one made up in the commonest fashion, and with the crudest pencil sketches."—Bul- letin of Med. Sciences. "We would advise every student of Medicine to procure it, while studying this por- tion of anatomical structure."—N. Y. Journ. of Med. "Enabling the student to identify the individual nerves in almost any part of the body, without additional assistance."—Boston Med. and Surg. Journ. —=§ tssm£jsmmmsa By S. HENRY DICKSON, M.D., Professor of the Institutes and Practice of Medicine in the Medical College of S.C. 1 small vol. 8vo. muslin. ience. John Macrobin, M.D. INTRODUCTION TO THE STUDY OF PRACTICAL MEDICINE : Being an Outline of the Leading Facts and Principles of the Scit 1 small vol. 8vo. half sheep. *i_!_^___-^?.=S^ __y, with advantage, gather a more extended system."- Western Lancet. 11 ¥ BARFUNGTON _ HASWELL'S f INDIGESTION. Robert Dick, M.D. DERANGEMENTS, PRIMARY AND REFLEX, ©_? _£___ ©_a®__f§ ©_? _)E(__^'ifn@_fo By ROBERT DICK, M.D., Author of" A Treatise on Diet and Regimen." 1 vol. 8vo. sheep. "Tt is the fullest, most comprehensive, and decidedly the best account of derangements of the digestive organs that we have encountered. While it embraces all that is important or interesting to°be found in the writings of other authors, it contains much original information, which the physician will find of great practical usefulness.'7—Western and Southern Medical Recorder. " We recommend this volume most warmly to the attention of our readers." —London Lancet, No. 937. " This volume may, in fact, be denominated with no small degree"of propriety an encyclopedia of dyspeptic disorders, and we unhesitatingly commend it, as the most useful and comprehensive treatise on this class of diseases with which we are ac- quainted."—N. Y. Lancet. " We have perused this work with pleasure and instruction. It is decidedly the best compilation in the English language on the extensive class of disorders and dis- eases comprehended under the term dyspepsia, united with a very large proportion of original matter, both in the form of able comments on other writers, and practical information derived from the author's own experience."—Mcd,-Chir. Rev. EPIDEMICS OF THE MIDDLE AGES. I. F. C. Hecker, M.D. EPIDEMICS OF THE MIDDLE AGES From the German of I. F. C. HECKER, M.D., Translated by R. G. BAB1NGTON, M.D., F.R.S. NO I. THE BLACK DEATH IN THE FOURTEENTH CENTURY. 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HASWELL'S -sj---------.----_------------------------------.----------------------------1» G. Hume Weatherhead, M.D. A PRACTICAL TREATISE ON THE PRINCIPAL DISEASES OF THE LUNGS. CONSIDERED ESPECIALLY IN RELATION TO THE PARTICULAR TISSUES AFFECTED, ILLUSTRATING THE DIFFERENT KINDS OF COUGH, By G. HUME WEATHERHEAD, M.D., Member of the Royal College of Physicians, Lecturer on the Principles and Practice of Medicine, and on Materia Medica and Therapeutics, etc., etc. 1 vol. 8vo. muslin. W. W. Gerhard, M.D. LECTURES ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE CHEST. By W. W. GERHARD, M.D., Lecturer on Clinical Medicine in the University of Pennsylvania, etc. 1 vol. 8vo. sheep. 2d edition just ready. NOTICES TO THE FIRST EDITION. " A series of clinical lectures—concise, lucid, and eminently instructive. 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Jour, of Mep. anp Surg. , " The present treatise will prove of great value, as it really contains all that is well known ; on this most difficult yet important branch of pathology and therapeutics."—West. I^incet. John Marshall, M.D. A PRACTICAL OBSERVATIONS 0 ON DISEASES OF THE HEART, LUNGS, STOMACH, LIVER, ETC. \|i OCCASIONED BY SPINAL IRRITATION: V AND ON THE NERVOUS SYSTEM IN GENERAL, AS A SOURCE OF ORGANIC DISEASE. Illustrated by Cases. \ By JOHN MARSHALL, M.D. 1 vol. 8vo. muslin. CUTANEOUS DISEASES. Samuel Plumbe. APRACTICAL TREATISE ON DISEASES OF THE SKIN. Their Constitutional Causes and Local Character, etc. By SAMUEL PLUMBE, Late Senior Surgepn to the Royal Metropolitan Infirmary for Children, &c. Illustrated with Splendid Coloured Copper-plate and Lithographic Engravings. New edition, greatly enlarged, in preparation. Plumbe on Diseases of the Skin.-" This excellent Treatise upon an ^der of diseases, the DatlioIoBVof which is, in general, as obscure as the treatment is empirical, has just been repub- Fished ttlUedby Dr. John Bell, of this city. We hail with pleasure he appearance of any new work calculated to elucidate the intricate and ill-understood subject ofskin-diseases. Ihe late n? MarkTritosh in his Practice of Physic, recommends it as the 'best pathological and prac- ?™w™i«°c» thU cla«B ofiseases which is to be found in any language.' "-Phil. Med. Exam U " ThU*w"rk?.one of?t£Tmost excellent on the Diseasesof the Skin in the English language." I — West. Jour, of Med. and Phys. Sciences. j\ —«==§$! If BARFUNGTON & HASWELL'S i Thomas Nunneley. | A TREATISE ON THE NATURE, CAUSES, AND TREATMENT OF ERYSIPELAS, By THOMAS NUNNELEY, Lecturer on Anatomy, Physiology, and Pathology in the Leeds School of Medicine, Surgeon to the General Eye and Ear Infirmary, &c, ifcc. 1 vol. 6vo. sheep. "Nothing short of a perusal of the entire book will do justice to the author or reader."— Western Lancet. " The work in its entireness is one which will be accounted necessary to every physician's library."—Western Journ. of Medicine and Surgery. " Did our space allow, it would be both interesting and profitable to enter into a full analysis of this work; but we would advise our readers, one and all, to purchase it, and thus judge of its value from a personal examination of its pages."—N. Y.Jour. Med. and Collat. Sciences. " Mr. Nunneley contends, and we think with success, that puerperal fever and ery- sipelas are one and the same disease, modified by the seat of the inflammation." — N. Orleans Med. Jour. CLINICAL MEDICINE. P. M. Latham, M.D. LECTURES ON SUBJECTS CONNECTED WITH CLINICAL MEDICINE. By P. M. LATHAM, M.D., Fellow of the Royal College of Physicians, and Physician to St. Bartholomew's, 1 vol. 8vo., newly arranged and enlarged, in preparation, sheep, " We strongly recommend them [Latham's Lectures] to our readers; particularly to pupils attending the practice of our hospitals."—Lond. Med. Gaz. Graves and Gerhard. CLINICAL LECTURES. By ROBERT J. GRAVES, M.D., M.R.I.A., Professor ofthe Institutes ofMedicine in the School of Physic, Trinity College, Dublin. WITH ADDITIONAL LECTURES AND NOTES, By W. W. GERHARD, M.D., Lecturer on Clinical Medicine to the University of Pennsylvania, Physician to the Philadelphia Hospital, Blockley, &c. 1 vol. 8vo. sheep. "In the volume before us, a series of clinical lectures by Dr. Gerhard is given, and forms a most appropriate and acceptable addition to those of Dr. Graves. Between these two distinguished physicians we can trace many points of resemblance. We find in both the same professional zeal, — the same powers of close aud correct observation,—the same discriminating tact, —the same disregard of idle theory, — and the same decision in the application of right principles. No stu- dent or practitioner should be without this volume. It is in itself a library of practical medicine " —X. Y. Lancet. MEDICAL PUBLICATIONS. G. Andral's CLINIC ON DISEASES OF THE ENCEPHALON. „ „ „ ABDOMEN. CHEST, Either of the works can be had separate! — each forming a distinct volume. Three vols. 8vo. sheep. " The ' Clinique Medicate'' is the great work of its distinguished author. It is an immense store- house of invaluable information in pathology and therapeutics. No medical library can be complete without it; and every physician, with the smallest pretensions to scientific attainment, or who is desirous of discriminating disease accurately, and of treating it skilfully, should study Us pages by day and night." " Andral's extensive researches in pathology entitle all his works to the careful considera- tion of the profession ; and all must agree that this great philosopher has enriched the science with many important truths, derived from that fruitful source, clinical observation and induc- tion."— Western Lancet. URINARY DISEASES. Robert Willis, M.D. URINARY DISEASES AND THEIR TREATMENT. By ROBERT WILLIS, M.D., Physician to the Royal Infirmary for Children, etc., etc. "Our notice of Dr. Willis's work must here terminate. It is one which we have read and trust again to read with profit. The history of discovery is successfully given ; cases curious and important, illustrative of the various subjects, have b?en selected from many new sources, as well as detailed from the author's own experience, chemical analyses, not too elaborate, have been afforded, which will be most convenient to those who wish to investigate the qualities of the urine in disease ; the importance of attending to this secretion in order to a proper un- derstanding of disease is strongly insisted upon: in short, a book has been composed, which was much required, and which we can conscientiously and confidently recommend as likely to be useful to all classes of practitioners."—Brit. 4- Foe. Med. Rev. v» — SURGERY. Abraham Colles. THE COURSE OF LECTURES ON SURGERY, Delivered in the Royal College of Surgeons in Ireland, By the late ABRAHAM COLLES, M.D., For Thirty-four year9 Professor of Surgery in the College. From notes collected and repeatedly revised by SIMON M'COY, ESQ., F-R.C.S.I. " We feel assured that no medical library in the kingdom will long remain devoid of these volumes."— Dublin Hospital Gazette. . «• We have no hesitation in affirming that they constitute a better body of surgery than is to be found in any volume which has been offered to the American profession in so accessible 1 ^^vTroncl^rur^fus^aSese .ectures with a very high opinion of the judgment and surgical acumen of the late Professor Colles, and can confidently recommend the work as one renlete with sound doctrines and practical facts. —Land. Mea. uai. 'PtL vnl..mrbeforeTus is evidently the work of a man of accurate observation and ex- tended expX °f a compi,er Wr" ttw»u'r^i8 kn0Wledge of diseases only from the recorded observations of others "-JV. Y Journ. of Med ''They are characterized by great vigor of thought, with a lingular simplicity of expression, which will fix the attention of the most careless reader. "Those who wish to study surgery, stripped of its technicalverbiage, murt read these lee lures as they fell from the lips of this distinguished Irisli professor."- JV. O. Med. and Surg. Journ. 17 2* —=&v BARRINGTON &. HASWELL'S Professor Gross, M.D. M ESHFISISlIIMISKr'S'AILi JmUD ©eiiie'iks.a.ili m@wnmT INTO THE ^ NATURE AND TREATMENT OF WOUNDS OF THE INTESTINES. By SAMUEL D. GROSS, M.D., Professor of Surgery in the Louisville Medical Institute. Illustrated by Engravings. 1 vol. 8vo. muslin. " We consider it a valuable contribution to our literature, and as worthy of the high reputa- tion of the author."—Philad. Med. Exam. "We dismiss the 'Experimental Inquiries,'fully persuaded that the valuable truths with which they abound, will be the best recommendation to the medical public."—AT. 0. Med. Jour. Liston and Gross. ELEMENTS OF SURGERY. By ROBERT LISTON, Fellow of the Royal College of Surgeons in London and Edinburgh, Surgeon to the Royal Infirmary, Senior Surgeon to the Royal Dispensary for the City and County of Edinburgh, Professor of Surgery in the London University, etc., etc. Eoitkd by SAMUEL D. GROSS, M.D., Professor of Surgery, Louisville Medical Institute. Author of Elements of Patho- logical Anatomy, etc., etc. Fourth American, from the last London Edition, with upwards of one hundred and sixty illustrative Engravings. 1 vol. 8vo. sheep. " We must not forget to mention that the volume is rendered still more attractive by the addition of numerous wood engravings (some of them introduced by Dr. Gross), all finely executed. These will be found of very considerable advantage to the student, materially assisting him in compre- hending the explanation of morbid structure. Another admirable feature, is the printing of the notes in type of the same size as that of the text. This obviates almost entirely whatever objec- tions can be alleged against foot-notes."—Western Jour, of Med. and Surg. " We are here presented with a republication of Mr. Liston's admirable and much praised work on Surgery, which has been subject to the alembic of a critical-anil learned friend, Dr. (imss. He has added 'copious notes and additions,' such as the progress of surgery in the United States demands in order to meet the wants of the surgeon. Professor Gross has also given an entire article on Strabismus, and another on Club Feet, which were wholly omitted in the English copies. They may be regarded important, inasmuch as they give a completeness to an otherwise unfinished treatise. The execution of the book is good; the paper firm, and well secured in the binding. The plates are uniformly well executed, and the impressions distinct."—Boston Med. and Surg. Jour. " In another essential feature this edition is greatly improved. With the principles is taught also with it the practice of surgery; and both morbid structure and operations are doui.ly described; first by the author and editor, and next by the graver of the artist."—Bull. Med. Scien. " Mr. Liston's reputation as a clear, accurate, and scientific surgical writer, is so widely known and admitted, that formal panegyric is quite unnecessary. Dr. Gross has discharged his duties as editor, with all the sound sense, accurate discrimination, and experienced judgment, which all who knew him expected. The additions and notes are indeed profitable and interesting ; and our only regret is, that they are not still more numerous than they are. The volume is inscribed to Profes- sor Parker, of the College of Physicians and Surgeons in this city,—the beauty of its typography, and • getting up,' will be readily taken for granted by all who know the publishers—and the illus- trative engravings are executed in a style very creditable to American art."—JV. Y. Lancet. " Mr. Liston has seen much, thinks accurately, and speaks independently. From a volume written by such a man, more really valuable practical instruction is to be derived than from all the books that were ever compiled."— Western and Southern Med. Recorder. "This is a work of established reputation. It has gone through two editions in Great Britain, and the same number in this eountry. The additions of the American edition are copious, and add materially to the value of the work.-'—Jimer. Jour. Med. Sciences. "The author is bold and original in bis conceptions, accurate in deductions, plain and con- cise in style ; a combination of good qualities not often found united in a single volume. The notes and additions by Prof. Gross, are well arranged and judicious, supplying some evident deficiencies in the original work."— Western Lancet. 13 MEDICAL PUBLICATIONS. Sir Astley Cooper, Bart. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. By FREDERICK TYRRELL, Esq., Surgeon to St. Thomas's Hospital, and to the London Ophthalmic Infirmary. Fifth American, from the last London Edition. 1 vol. 8vo. sheep. John Hunter. LECTURES ON THE PRINCIPLES OF SURGERY. By JOHN HUNTER, F.R.S. With Notes, By JAMES F. PALMER, Senior Surgeon to the St. George's and St. James's Dispensaries, etc., etc. With Plates, 1 vol. 8vo. sheep. •• We cannot bring our notice of the present volume to a ^^^^"l^J^^l to the admirable manner in which the editor and annotator has fulfilled hipart of the under takin» The advancements and improvements that have been effected, up toourown*ay, not only"n practical sursery, but in all the collateral departments, are.=ons tantly brought before the reader's attention in clear and coneise terms."-£nt. % For. Med. Rev. VENEREAL. John Hunter, F.R.S. TREATISE ON THE VENEREAL DISEASE. With Notes, By Dr. BABINGTON. With Plates. 1 vol. 8vo. "Under the hands ^^^^J^™^ task £ editor* a very exemplary « ThP .,ntP< in illustration of the text, contain a summary of our present know- apprehen.iL of the disease. WeWd recommend to to^eyhe^o* primary venereal sore; the note itselt is an essay in every v»«.u concur."—Med. Gaz. BARRINGTON &. HASWELL'S THE SPINE. R. W. Bampfield. ON CURVATURES & DISEASES OF THE SPINE, INCLUDING ALL THE FORMS OF SPINAL DISTORTION, By R. W. BAMPFIELD, One of the Surgeons to the Royal Metropolitan Infirmary for Diseases of Children. Edited by J. K. MITCHELL, M.D.', Professor of the Practice of Medicine in Jefferson Medical College of r Philadelphia, &c, &c. " The very best treatises on spinal diseases and their treatment extant."—Med. Exam. " We heartily recommend this book to all who feel an interest in the matter, and especially in these days of degenerating specialties."—New York Journal of Medicine. " The treatise is a very valuable-one, and we cheerfully recommend it to the pro- fession." — New Orleans Med. Journ. TH E EAR. George Pilcher. A TREATISE ON THE STRUCTURE, ECONOMY, AND DISEASES OF THE EAR. BEING THE ESSAY FOB. WHICH THE FOTHERGILLTAN GOLD MEDAL WAS AWABDED BY THE MEDICAL SOCIETY OF LONDON. By GEORGE PILCHER, Late Lecturer on Anatomy, Lecturer on Surgery at the Theatre of Anatomy and Medi- cine, Webb St., Borough, and Senior Surgeon to the Surrey Dispensatory. First American, from the Second London edition, with Notes and numerous Illustrative Plates. 1 vol. 8vo. sheep. " The perusal of this work has afforded us much pleasure — A work was wanted to place the whole subject within the grasp of all persons who chose to devote some little exclusive or particular study to the diseases of the ear, and this has fairly and well supplied the place."—Med. Chir. Rev. " Mr. Pilcher is an experienced, well-informed, and able practitioner, and his treatise on the ear deserves to be ranked amonsstthe best which have appeared upon the interesting,but too generally neglected, department of surgery to which it relates."—Maryland Med. and Suijg. Journ. "This is a most valuable treatise, illustrated with elegant plates, is a standard work, and must have a great sale in its present form. It tells all about the anatomy and diseases of the ear."— N. Y. Herald. GUMS. George Waite. THE GUMS: WITH LATE DISCOVERIES ON THEIH STRUCTURE. GROWTH, CONNECTIONS, DISEASES, AND SYMPATHIES. By GEORGE WAITE, Member of the London Royal College of Physicians. 20 m=— MEDICAL PUBLICATIONS. TEETH. Just published. Fox & Harris. THE NATURAL HISTORY DISEASES OF THE HUMAN TEETH. By JOSEPH FOX, M.R.C.S.L. Member of the Society of Medicine, Paris ; Lecturer on the Structure and Diseases of the Teeth, at Guy's Hospital; and Surgeon-Dentist to their Royal Hignesses the Dukes of Kent and Sussex. First American from the Third London Edition. Remoddeled, with an Introduction, and nearly tivo-thirds of additional matter. ByCHAPIN A. HARRIS, M.D.,D.D.S. Professor of Practical Dentistry and Dental Pathology in the Baltimore College of Dental Surgeons; Member ofthe Medico-Chirurgical Faculty of Maryland ; Author of Principles and Practice of Dental Surgery, &c, &c. Illustrated -with Thirty Plates. 1 vol., super-royal, 8vo. sheep. John Hunter. A TREATISE ON THE TEETH. By JOHN HUNTER. With Notes, by THOMAS BELL, F.R.S. With Plates. 1 vol. 8vo. muslin. •• The treatise on the teeth is edited by Mr. Bell, a gentleman accomplished in his art. Mr. Bell has studied his subject with the greatest minuteness and care; and in appropriate notes at the foot of the page corrects the author with the air of a gentleman, and the accuracy of a man of science. The matter contained in these short notes forms an ample scholum to he Sit; and without aiming at the slightest display of learning, they at the same time exhibit a readyknowledge on every point, and an extensive information both of comparative ana and pathology."—Med. Gazette. 21 BARRINGTON &. HASWELL'S MINOR SURGERY. Henry H. Smith, M.D. MINOR SURGERY: ®is@ssr= By HENRY H. SMITH, M.D., Lecturer on Minor Surgery, Fellow of the College of Physicians, etc., etc. Illustrated by numerous Engravings. 1 vol. 18mo. muslin. « And a capital little book it is.....Minor Surgery, we repeat, is really Major Sur- gery and any thing which teaches it is worth having. So we cordially recommend this little book of Dr. Smith's."—.Wed. Chir. Rev. " This beautiful little work has been compiled with a view to the wants ot the pro- fession in the matter of Bandaging, &c, and well and ably has the author performed his labours."—Med. Examiner. ,-,•.• " To students we would particularly recommend Dr. Smith's work; and with it in their possession, they would be able to cany out to great advantage the advice of an eminent professor of a neighbouring city — ' Provide yourselves each with half a dozen rollers, and after your day's study is over, just before going to bed, amuse yourselves by bandaging each other. It is the only way to acquire an art, ignorantly underrated but of immense importance.' "—Boston Med. and Surg. Journ. "This is an excellent Treatise on Bandaging,and will prove of great assistance to the student and to the country practitioner." " The book is very handsomely illustrated with a great number of excellent wood-cuts. The paper and type are good. We repeat, in conclusion, our very favour- able estimation of its merits."—Med. Exam. . "We venture to predict for this little volume a successful career, for we have here a means adantedtoanercd." " Here are furnished to the student all the various inventions and modifica- tions of bandages and apparatus, more especially by the American Surgeons, Physick, Dorsey, Gibson, Barton, Coates, Hartshorne, and N. R. Smith. "-2V. Y. Jour, of Med. " We have no hesitation in asserting, that it is an excellent, we. were going to say indispensable, aid to all those who wish to qualify themselves for the practice of 8urgery."-£wZZ. of Med. Science. MIDWIFERY" AND DISEASES OF WOMEN, Robert Lee. LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY. delivered in the theathe of st. geohge's hospital. By ROBERT LEE, M.D., F.R.S., Fellow of the Royal College of Physicians, London; Physician to the British Lying-in Hospital; and Lecturer on Midwifery at St. George's Hospital. Illustrated with numerous Wood Engravings. 1 vol. 8vo. " Dr. Lee's former reputation for large practical knowledge of obstetrics is fully sustained in the present work." " The style is plain and clear, and the facts and cases are presented with due succinctness. One important feature is the introduction of tables of the results of certain operations, as of craniotomy, and of certain diseases of the puerperal state, as puerperal fever; which constitute a statistical basis for future observations and a present support for active and available practice."— Bulletin of Medical Science. " Dr. Lee is too good and sensible an author to be reviewed. He should be read. He has already, though but a young man, become illustrious by his earlier works." —Philad. M~ed. Exam. " We can cheerfully commend it to the notice of students of medicine."— Western Lancet. * " It is the production of a highly cultivated and practical mind, and has been ela- 92 MEDICAL PUBLICATIONS. borated with a degree of judgment and care which must render the Lectures a valu- able record of professional learning and experience."—Western Journal of Med. Sc ICtl CCS " While they are well adapted for the instruction of the student of midwifery, the Lectures of Dr. Lee may be consulted by the young practitioner with much satisfac- tion and profit. The wood engravings, by which the text is accompanied, are well executed, and communicate a very accurate idea of the subjects they are intended to illustrate."—Amer. Jour. Med. Science. ... " Every passage will indicate in the author a discriminating, practical mind, en- lightened by learning, and extensive observation." "It is a store-house of facts from which the student may enrich his mind, and to which the practitioner may apply to refresh his memory."— Western Jour. " The aim of the publishers was to give to the profession one of the very best systems of midwifery in the language for the least money — to place a volume of unquestionable excellence within the reach of every medical man in the country. They have been successful."— Ibid. . " The present production of Dr. Lee will always rank high, as the offspring of a vigorous mind, stored with all the learning relating to the subject, and enriched with the results of the most extensive experience." — N. Orleans Med. Jour. James Blundell, M. D. LECTURES ON THE PRINCIPLES AND PRACTICE OF MIDWIFERY. By JAMES BLUNDELL, M.D. Edited by Charles Severn, M.D. 1 vol. 8vo. sheep. " The eminently fluent and agreeable style—the large and accurate information —the great experience,and original mind of Dr. Blundell, have secured for him a very enviable reputation as a public lecturer. It is impossible to read these lectures without being delighted -it is equally im- possible to avoid being instructed. Were these discourses more generally diffused and studied here -were their sound and judicious directions recollected, and their salutary cautions observed, we would hear of fewer cases of malpractice. This work.forms a complete system of midwifery, with the diseases of the puerperal state and of the infant."— -N. Y. Lancet. Robert Collins, M.D. A PRACTICAL TREATISE ON MIDWIFERY. containing the results of sixteen thousand six hundred and fifty-four BIRTHS, OCCURRING IN THE DUBLIN LYING-IN HOSPITAL. By ROBERT COLLINS, M.D., Late Master of the Institution. 1 vol. 8vo. sheep. « The author of this work has employed the numerical method of M. Louis) and by accurate tablesof classification, enables his readers to perceive, at a glance, the consequences of the diversified conditions, in which he saw his patients. A vast amount of information is thus contained.which is invaluable to those who duly appreciate precision in the examination of cases."—Bait. Citron. Robert Gooch, M.D. i PRACTICAL COMPENDIUM OF MIDWIFERY, Being the Course of Lectures on Midwifery, and on the Diseases of Women and Infants delivered at St. Bartholomew''s Hospital. By the late ROBERT GOOCH, M.D. PREPARED BY GEORGE SKINNER, Member of the Royal College of Surgeons, London. 1 vol. 8vo. sheep. BARRINGTON & HASWELL'S PUERPERAL FEVER. Gordon, Hey, Armstrong, Lee, and Meigs. THE HISTORY, PATHOLOGY, AND TREATMENT OF I PUERPERAL FEVER AND CRURAL PHLEBITIS. \ By Drs. Gordon, Hey, Armstrong, a>d Lee. \ With an Introductory Essay \ By CHARLES D. MEIGS, M.D., 't Professor of Obstetrics and the Diseases of Women and Children in the Jefferson \ Medical College, Philadelphia. 't 1 vol. 8vo. sheep. { " We have peculiar satisfaction, In announcing the publication of this very judiciously arranged I serb s of treatises, on one of the most important and interesting diseases, which demand the atten- 5 tion of the physician." "Dr. Meigs's Introductory Essay is concise and judicious, and will be read \ with profit. He speaks in the highest terms of commendation of Dr. Gordon's invaluable treatise — \ a treatise which cannot be too generally diffused and studied. Altogether this volume presents the { most acceptable and useful compend of the doctrines and practice of the best authorities, with £ regard to ' Puerperal Fever,' with which we have ever met."—N. Y. Lancet. " We are pleased to see the republication of these valuable monographs upon Puer- Aperal Fever. As they are all of them Essaysfounded upon an extensive observation, and contain a very large number of recorded cases, they must always be valuable." — Neto England Journal of Medical Science. " Taken in connexion, the treatise it comprises present an invaluable mass of facts in relation to Child-bed Fever, without an acquaintance with which no one can, with propriety, be considered fully qualified to undertake its management."—Journal of Medical Science. UTERUS. Waller, Lisfranc, and Ingleby. LECTURES ON THE FUNCTIONS AND DISEASES OF THE WOMB, By CHAS. WALLER, M.D., Bartholomew's Hospital. ON DISEASES OF THE UTERUS AND ITS APPENDAGES. By M. LISFRANC, La Pitie Hospital. ON DISEASES OF THE PUERPERAL STATE. By J. T. INGLEBY, Edinburgh. 1 vol. 8vo. sheep. " We can very cordiallyrecommend them as affording a concise and practical exposition of the pathology and treatment of a most important class of diseases, and which cannot be loo attentively studied."—N. Y. Lancet. " The present volume contains a short and succinct practical account of the principal morbid states either of the functions or the structure of the womb, the best methods of distinguishing them, and the means which experience has shown to be the most effectual in removing them. The reader will find that he obtains, in a small compass, a distinct view of the nature and treatment of each disorder."—Edinb. Med. and Surg. Journ. MEDICAL PUBLICATIONS. TO XICOLOGY. Robert Christison, M.D. A TREATISE ON POISONS IN RELATION TO MEDICAL JURISPRUDENCE, PHYSIOLOGY, AND THE PRACTICE OF PHYSIC. By ROBERT CHRISTISON, M.D., F.R.S.E., Professor of Materia Medica in the University of Edinburgh, &c, &c. " We cannot but hail with satisfaction a new edition of this standard classical book. It merits are too well acknowledged for it to be necessary to say anything further in its behalf. Wherever Toxicology is known as a science, Professor Christison's Treatise is received as an authority of the greatest weight." — Lancet. " It has, for a long period, been in the hands of barristers, who have not failed to make a good use ofit in the cross examination of medical witnesses; and we believe there are few medical men who venture into the witness box on a trial for poisoning, without having at least consulted it respecting some point on which their evidence is likely to be impugned."— Lond. Med. Gaz. " Such is a most imperfect sketch of this most valuable work. It would be an ac- quisition to any medical library, and we think particularly so to our friends in this part of the world.'' — New Orleans Jfcd. Journ. "The First American from the Fourth Edinburgh edition of this unsurpassed work has appeared. The American profession will have within their reach the ablest treatise in the language on the subject of poisons." — Western Journal. "The work of Professor Christison being recognised, by common consent, as the standard authority on this subject, it is unnecessary to do more than announce its publication."— New York Journal of .Medicine. "It would be a work of supererogation, at the present day, to speak of the merits {j of this work. It has long and justly been regarded as one of our standard authori- a ties." — Med. Exam. .. ,, VW/ " Dr. Christison's is a very superior guide for the general practitioner and student. W — Med. Chir. Rev. . ,.,..., 1 "A work abounding in original observations and opinions, exhibiting the science ; of Toxicology in its present advanced state, and entitled therefore to take the first rank in its ctass, is what might have been looked for from his pen."—West. Jour. ~\Tefl Sciences• "We arc free to say that it is the best book on the subject in the English lan- guage."— Western Lancet. ... » This book is of the very highest authority on the subject of poisons, and may be said to exhaust it."— Western Law Library. .,. , , , "The author has, with singular industry, brought within the compass of a single volume 'every variety of useful information and illustration connected with the subject. It is an'invaluable addition to the Library of the Advocate." —Am. Law Library. " It has now deservedly become a standard authority in courts of law; and, on all difficult questions connected with toxicology, it is a work for reference to judges, barristers, and medical practitioners."—Brit, and For. Med. Rev. Extract from a letter of Chief Justice Taney, dated Baltimore, July 28, 1845. " The whole subject is clearly and well arranged, and the symptoms, effects, and tests of different poisons very fully and plainly stated. Accept ray thanks for the book It cannot fail, I think, to be generally consulted and approved by those who, from professional duty, or any other motive, may be called upon to investigate the difficult, and often painfully delicate subject, of which it treats. Extract from a letter of Judge Story, dated Cambridge, April 18, 3845. " I return yon my sincere thanks for your kindness in presenting me with a copy of Professor Christison's Treatise on Poisons. It appears to me to be a most vain- «=w DISEASES OF CHILDREN. Evanson and Maunscll. PRACTICAL TREATISE ON THE DISEASES AND MANAGEMENT OF CHILDREN. By RICHARD T. EVANSON, M.D., Professor of Medicine, — and HENRY MAUNSELL, M.D., Professor of Midwifery — in the College of Surgeons, Ireland. Edited by D. F. CONDIE,M.D. From the Fourth Dublin Edition. 1 vol. 8vo. sheep. " The second chapter embraces the Management and Physical Education of Chil- dren. This chapter ought to be printed in gold letters, and hung up in the* nursery of every family. It would save many lives, and prevent much suffering."—Medico- Ckirurg. Rev. " As this Practical Treatise on the Diseases of Children has before been made known to the medical public, we dare not suppose it a new thing to any intelligent practi- tioner in this country ; still, there may be those who do not own a copy—and to such there is nothing ungenerous in saying we wish that they may always have it in their power to consult such authority."—Bosto7i Med. and Surg. Journ. " The present edition is enlarged, and in its present form constitutes one of the best works on the subject in our language.''—Philad. Med. Exam. Michael Underwood, M.D. A TREATISE ON THE DISEASES OF CHILDREN. WITH DIRECTIONS FOR THE MANAGEMENT OF INFANTS. By the late MICHAEL UNDERWOOD, M.D. By S. Merrjman, M.D., and Marshall Hall, M.D., F.R.S., Etc. with notes, by john bell, m.d., etc., of Philadelphia. From the Ninth English Edition, with Notes, 1 vol. 8vo. sheep. Thomas J. Pettigrew. ON SUPERSTITIONS CONNECTED WITH THE HISTORY AND PRACTICE OF MEDICINE AND SURGERY. By THOS. JOSEPH PETTIGREW, F.R.S., F.S.A., Doctor of Philosophy to the University of Gbttingen, &c, &c 1 vol, 12mo. " The book will prove instructive, not only on account of the extensive learning which it displays, but the numerous and curious facts which it develops."—JV. Orleans Med. Jour. " Mr. Pettigrew's book is amusing to such as are inclined to smile, and instructive to those who are willing to reflect."—Med. Chir. Rev. " From the follies of the past we may derive wisdom for the future, and there is much in the volume before us that may be profitably used for this purpose."—Med. Exam. " It is the common-place book of a literary physician with a running commentary, giving a unity and continuity to the mosaic."—Brit, and For. Med. Rev. " We do not know of pleasanter reading, either for the physician in the between- whiles of professional labour, or for the general reader who loves to study human nature in its external and often eccentric workings."—Bull. Med. Science. " We heartily commend this little work to the curious of all classes of readers."__ N. Y. Journ. Med. and Collat. Sciences. A" We take leave of his book, from which we have derived not only entertainment but instruction."—Jf est. Journ. 26 MEDICAL PUBLICATIONS. J. L. Ludlow, M.D. A MANUAL OF EXAMINATIONS UPON ANATOMY AND PHYSIOLOGY, SURGERY, PRACTICE OF MEDICINE, CHEMISTRY, MATERIA MEDICA, OBSTETRICS, ETC. Designed for the Use of Students of Medicine throughout the United States. By J. L. LUDLOW, M.D. 1 vol. 12mo. "In this ' Manual of Examinations' the questions are clearly put, and, with few exceptions, well and distinctly answered." " The Manual will be found to be equally available at the three schools in Philadelphia, as at the two in New York, or those of Louisville, Lexington, and Cincinnati, or of Charleston, Augusta, and New Orleans, not to mention the numerous confreries for teaching down East." —Bull. Med. Science. "We have no hesitation in saying, that Dr. Ludlow's Manual is decidedly the best, both in relation to comprehensiveness and general accuracy, that has yet been published in this country."—Western Lancet. " Dr. Ludlow discovers a minute knowledge with all the leading departments of professional lore, which he imparts agreeably. He is careful to be exact, without bein" redundant in any paragraph."—BostonMed. and Surg. Jour. " Between all the classes whose comfort the Student's Manual is designed to pro- mote, we should think it would obtain not a little currency."—West. Journ. Jas. W. Dale, M.D. IS MEDICAL SCIENCE FAVOURABLE TO SCEPTICISM! By JAMES W. DALE, M.D. of Newcastle, Del. Pamphlet. G. R. B. Horner. M.D.. U.S.N. MEDICAL AND TOPOGRAPHICAL OBSERVATIONS UPON THE MEDITERRANEAN AND UPON PORTUGAL, SPAIN, AND OTHER COUNTRIES. ByG. R. B. HORNER, M.D., Surgeon U. S. Navy, and Honorary Member of the Philadelphia Medical Society. With Engravings. 1 vol. 8vo. muslin. " An uncommonly interesting book is presented to those who have any disposition to know the things medical in Portugal, Spain, and other countries," and " will doubtless be read, also, with marked satisfaction by all who have a taste for travels."—Bost. Med. and Surg. Jour. John G. Malcolmson, M.D. CLINICAL REMARKS ON SOME CASES OF LIVER ABSCESS PRESENTING EXTERNALLY. Bv JOHN G. MALCOLMSON, M.D., Surgeon Hon. E. I. C. Service, Fellow of the Royal Asiatic Society, and the Geological Society, London. 1 vol. 8vo. MEDICAL PUBLICATIONS. Thomson and Twining. DISEASES OF THE LIVER AND BILIARY PASSAGES. By WILLIAM THOMSON, One of the Physicians of the Royal Infirmary of Edinburgh ; AND CLINICAL ILLUSTRATIONS OF THE LIVER AND SPLEN. By WILLIAM TWINING, Surgeon of General Hospital of Calcutta, &c, &c. 1 vol. 8vo. sheep. " The work before us is an excellent compilation of the subject of hepatic affections, functional and structural; and, as such, it is infinitely more valuable to practitioners and students, than any original essay, however ably executed. We cannot do better, therefore, thnn strongly recommend the work as the best in the English language, on the important subjects of which it treats."— Medico-Chirurg. Rev. Wm. C. Wells, M.D. N ESSAY ON DEW, And several appearances connected with it. Br WILLIAM CHARLES WELLS, M.D., F.R.S. JOHN HUNTER'S WORKS. Comprising his Lectures on the Principles of Surgery; A Treatise on the Teeth ; Treatise on the Venereal Diseases ; Treatise on Inflammation and Gunshot J Founds ; Observations on Certain Parts of the .lnimal CEconomy; and a full and comprehensive Memoir. Each of the Works is edited by men of celebrity in ihe Medical Science, and the whole under the superintendence of JAMES F. PALMER, Of the St. George's and St. James's Dispensary. 4 vols. 8vo. This is the only complete edition of the works of the distinguished physiologist ever published in this country. "One distinctive feature of the present edition of Hunter's works has been already men- tioned, viz.; in the addition of illustrative notes, which are not thrown in at hazard, but are written by men who are already eminent for their skill and attainments on the particular subjects which they have thus illustrated. By this means, whilst we have the views of John Hunter in the text, we are enabled by reference to the accompanying notes, to see wherein the author is borne out by the positive knowledge of thp present day, or to what extent his views require modification and correction. The names of the gentlemen who have in this manner assisted Mr. Palmer, are guarantees of the successful performance of their task."—Wed. Gaz. Drewry Ottley. THE LIFE OF JOHN HUNTER, F.R.S. By DREWRY OTTLEY, 1 small vol. 8vo. " In the summing up of Mr. Hunter's character, Mr. Ottley exhibits equaljudg meutand candour."—Brit, and For. Med. 28 f® -£ 3=--------- Any person ordering Books to the value of Ten Dollars from the following list, and remitting the amount free of postage, will be entitled to the Bulletin of Medical Science for one year, gratis. LIST OF WORKS SUPPLIED AS SELECT MEDICAL LIBRARY EXTRAS, —BY MAIL. Barrington and HaswellwUI furnish the following Works as Extras ,• they are stitched in thick paper covers, with strong elastic backs, similar to the regular numbers; they can be sent by mail, charged as Periodicals. To the name of each work is stated the selling price; so that any gentle- man desirous of having one or more Extras will, by remitting a note, (or order payable in Philadelphia,) be furnished, by return of mail, with what- ever he may select, to the amount. Post-masters are at liberty to receipt for $10, who must forward the Receipt to the Publishers and an order on the Philadelphia Post-master for the amount. N.B. Those works comprised within brackets are bound in one volume, and must be ordered as one Extra. Ludlow's Student's Manual . . • • • • . $1 60 Pettigrew's Superstitions Connected with the History and Practice of Medicine and Surgery .... ... 50 Lee's Observations on the Principal Medical Institutions and Practice"! of France, Italy, and Germany, &c.; with an Appendix on Animal | Magnetism and Homoeopathy . • • • . )• . 1 35 Johnstone's Syllabus of Materia Medica . . . . . j Latham's Lectures on Clinical Medicine . . . . J A Treatise on Tetanus. By Thomas B. Curling. . ) Bouillaud on Acute Articular Rheumatism in general. Translated from > . 80 the French, by James Kitchen, M.D. . . • • ) Practical Obsei vations on Diseases of the Heart, Lungs, Stomach, ) Liver, &c. By John Marshall, M.D., &c. . . . V . 80 Wealherhead on Diseases of the Lungs . . • • J Smith's Minor Surgery . . , • • • . 1 00 Davidson and Hudson's Essays on the Sources and Mode of Action of Fever ....-•••• 80 Macrobin's Introduction to the Study of Practical Medicine . . 70 Sir James Clark on the Sanative Influence of Climate • . .80 Changes of the Blood in Disease. By M. Gibert . . 50 Sir Charles Bell's Institutes of Surgery . . . • . 1 50 Epidemics of the Middle Ages, by Hecker - ... 60 39 m=— MEDICAL PUBLICATIONS T i Magendie's Lectures on the Blood . . . . 1 25 Holland's Medical Notes and Reflections . . .. 1 60 Army Meteorological Register for the years 1826, 1827,1828,1829, and "l 1830. r Hints on the Medical Examination of Recruits for the Army. By f Thomas Henderson, M.D., Assistant Surgeon U. S. Army, &c.j Sfr>— Bampfield on Curvatures of the Spine. Including all the Forms of Spinal Distortion ..... ... $1 25 Nunneley's Treatise on the Nature, Causes, and Treatment of Erysipelas 1 25 Williams's Principles of Medicine Comprehending General Pathology and j Therapeutics . . . • • ■ • . 1 *5 | Lee's Theory and Practice of Midwifery. Illustrated with numerous En- j gravings . . . • • • • • . a 00 > TurnbnlPs Treatise on the Medical Properties of the Natural order"! $ Ranunculacese, &c.,&c. The Gums; their Structure, Diseases, Sympathies, &c. By George f 8o Waite An Essay on Dew, &c. By W. C. Wells, F.RS* Collins's Practical Treatise on Midwifery . . . . 1 25 Evanson and Maunsell on the Management and Diseases of Children. With Notes, by D. F. Condie, M.D. . . • - . 1 75 Edwards on the Influence of Physical Agents on Life ; wir#observations on Electricity, &c. ..... 1 00 Horner's Necrological Notice of Dr. P. S. Physick. ^ Is Medical Science Favourable to Scepticism ? By Dr. Dale, of New- J castle, Delaware } .30 On Dengue its History, Pathology, and Treatment. By Prof. Dick- | son of S. C. J Freckleton's Outlines of General Pathology ... .75 Urinary Diseases and their Treatment. By R. Willis, M.D., &c. . : 1 00 Andral's Medical Clinic : 3vols.8vo. Diseases of the Encephalon, 1 vol. . . . 1 50 Diseases of the Abdomen, „ • • • . » 1-50 Diseases of the Chest, „ . . . . . 1 50 Aran's Practical Manual on Diseases of the Heart and Great Vessels. 1 vol. 18mo. ........ 75 A Treatise on the Structure, Economy, and Diseases of the Ear. By George Pilcher. With numerous illustrative Plates • . . .. 1 75 Lectures on Bloodletting. By Dr. Clutterbuck . .65 Medical and Topographical Observations upon the Mediterranean. By G.R. B. Horner, Surgeon U.S.N., &c. Illustrated with Engravings . . 1 00 FURNISHED BY MAIL. Macartney on Inflammation . • . • • ■ . $ 50 Burne on Habitual Constipation — its Causes and Consequences . . 75 Esquirol on Mental Diseases. \ \ 00 An Essay on Hysteria. By Thomas Laycock. J Clinkial Remarks on Liver Abscess. By John G. Malcolmson, M.D., Thomson's Notices of Inflammatory Affections of the Internal Organs after External Injuries and Surgical Operations. Gooch's Practical Compendium of Midwifery . . . . .100 i 45 V3V Graves Clinical Lectures. With Notes and Fifteen additional Lectures, by W. W. Gerhard, M.D........2 50 Elements of Surgery. By Robert Liston. Edited by Samuel D. Gross, M.D., Professor of Surgery. 1 vol. 8vo. . . . . . . 3 00 The History, Pathology, and Treatment, of Puerperal Fever and Crural Phlebitis. By Drs. Gordon, Hey, Armstrong, and Lee; with an Introduc- tory Essay by Charles D. Meigs.'M.D. 1 vol. 8vo. . • . . 1 60 Derangements, Primary and Reflex, of the Organs of Digestion. By Robert Dick, M.D. 1 vol. 8vo........1 40 Diseases of the Liver and Biliary Passages, by William Thomson. And Clinical Illustrations of the Liver and Spleen. By William Twining. 1 vol. Svo.......• . . 1 60 A Treatise on the Diseases of Children, with directions for the Management of Infants ; by the late Michael Underwood, M.D. From the ninth English edition, with notes by S. Merriman, M.D., and Marshall Hall, M.D., F.R.S;, &c. With notes, by John Bell, M.D., &c. . . . .175 Lectures on the Functions and Diseases of the Womb; by Charles"! Waller, M.D., Bartholomew's Hospital. j On Diseases of the Uterus and its Appendages; by M. Lisfranc, La I # 1 16 Pitie Hospital. i On Diseases of the Puerperal State; by J. T. Ingleby, Edinburgh, | 1 vol. 8vo. J Aphorisms on the Treatment and Management of the Insane ; by J. G. Mil- lingen, M.D. ......... 38 A Practical Dictionary of Materia Medica. By John Bell, M.D. 1 vol. 8vo. 2 25 Outlines of Pathological Semeiology. Translated from the German of Prof. Schill. 1 vol. 8vo. . . . • • • • . 1 00 Aretaeus on the Causes and Signs of Acute and Chronic Disease. From the Greek. 1 vol. 8vo. ........ 50 Blundell's Lectures on the Principles and Practice of Midwifery. Edited by Charles Severn. 1vol. 8 vo. . . • • • .2 00 Christison on Poisons . . • • • • • 2 50 Colles' Surgical Lectures . . • • • • : 1 50 Heberden's Commentaries . . . • • • • * M Neill on the Arteries. Coloured Plates . . • • . 1 00 - Nerves. Plates....... 1 00 31 WORKS IN PREPARATION. On the Diseases of Females : With special reference to their Hy- gienic Prevention and. Treatment. By John Bell, M.D. In this work, the author will take pains to point out the hygienic measures required for the prevention of the diseases to which, by her anatomical and physiological peculiarities, the female is liable, independently of the merely sexual organs. The differ- ences in the nervous system, state of the blood, &c, indicate the necessity of differences, or, at any rate, notable modifications in both her physical and medical treatment. From birth, her future destiny and exposures, as mother, ought to receive more attention, in reference to the laws of hygiene, than has hitherto been given to the subject. The relative frequency of the dis- eases of the sex in different periods of life, and the value of particular modes of treatment, will be tested as much as possi- ble by statistical returns; thus correcting the fluctuations of opinion and the obtrusions of hypothesis. Principles and Practice of Medical Jurisprudence. By John Bell, M.D. A Latham's Medical Clinic : comprising Diseases of the Heart. The Physiology, Hygiene, and Pathology of Persons engaged in pur- suits requiring intense Mental Application. By D. Spillan, A.M., M.D., &c, &c. Clinical Lectures on Syphilitic Diseases. By Richard Carmichael, M.R.I. A., President of the Medical Association of Ireland, &c. A Course of Lectures on those Diseases of the Brain which affect the Mind, and produce Insanity. Delivered in Paris, by M. Baillarger, Physician to the Hospital Salpetriere. Connelly's Lectures on Insanity. Practical Commentaries on the Treatment of Dyspepsia in all its forms : By Robert Dick, M.D. Now in Press. Lectures on the Nature and Treatment of Deformities, delivered at the Orthopoedic Institution, Bloomsbury Square : By R. W. Tamplin, F.R.C.S.E., Surgeon to the Institution. With Engravings. A .-—=8 THEOLOGICAL AND SCHOOL BOOKS. BARRINGTON & HASWELL ALSO PUBLISH A VERY POPULAR EDITION OF THE OLD AND NEW TESTAMENT Without Note or Comment, in large type, 1 vol. 8vo. This edition is put up and may be had either with or without the Apocrypha, Con- cordance, Psalms, or Plates. . . . Their fine edition is of superior workmanship, and the paper on which it is printed has all of the firmness, consistency, and colour of the best European. They are in all styles of binding. u <} V '4 AN EXPOSITION OF THE OL.D ANB NEW TESTAMENT. Wherein each chapter is summed up in its contents ; the sacred text inserted "at large, in distinct paragraphs; each passage reduced to its proper heads; the sense given, and largely illustrated. "WITH PRACTICAL REMARKS AND OBSERVATIONS, By MATTHEW HENRY. Edited by the Rev. Geo. Burder, and the Rev. Joseph Hughes, A.M.; with the Life of the author by the Rev. Samuel Palmer. TO WHICH IS PREFIXED A P REFACE. By ARCHIBALD ALEXANDER, D.D., Professor of Theology in the Seminary at Princeton, New Jersey. First American edition, 6 vols- super 8vo. This work has elicited so decidedly the approbation of the most judicious men of the principal denomination of Christians in the United States, that the publishers deem it unnecessary to offer now many of the numerous recommendations they have received from various quarters. The following will serve to show the universal opinion with regard to this work : From the Rev. S. H. Cone, Pastor of the Oliver Street Baptist Church, New York. ave examined the stereotype edition of Matthew Henry's Exposition of the d New Testament, and take pleasure in bearing testimony to its typographical 33 £3s=- T -~—~'—"=k©; THE OL O GICAL P UBLICA TIOJVS. neatness and accuracy, and the comparative cheapness of price at which it is now offered to the American public. " With^reference to the intrinsic excellence ofthe work itself, it needs not my feeble commendation. The wise and good unite in saying, that it is calculated to render those who read it wiser and better; and having frequently derived from it edification and comfort myself, I do sincerely hope you may succeed in circulating it extensively among my fellow-citizens." The following vivid delineation of its characteristic qualities is from the pen of the Rev. Dr. Alexander, of Princeton : " A characteristic of this Exposition of a more important kind than any that have been mentioned, is, the fertility and variety of good sentiment manifest throughout the work. The mind ofthe author seems not only to have been imbued with excellent spiritual ideas, but to have teemed with them. It is comparable to a perennial foun- tain, which continually sends forth streams of living water. In deriving rich instruc- tion and consolation from the sacred oracles, adapted to all the various conditions and characters of men, the author displays a fecundity of thought, and an ingenuity in making the application of divine truth, which strikes us with admiration. The resources of most men would have been exhausted in expounding a few books ofthe Bible; after which little more could have been expected than common-place matter, or a continual recurrence ofthe same ideas ; but the riches of our Expositor's mind seem to have been inexhaustible. He comes to every successive portion ofthe sacred Scriptures with a fulness and freshness of matter, and with a variety in his remarks, which, while it instructs, at the same time refreshes us. Even in his Expo- sition of those books which are very similar in their contents, as the gospels for ex- ample, we still fine a pleasing vatiety in the notes of the commentator. It is difficult to conceive how one man should have been able to accomplish such a work, without any falling offin the style of execution." The Rev. Edward Bickersteth says —" There is in Matthew Henry a glow of love, a full exhibition ofthe sense, a happy reference to the passage expounded, and lively cheerfulness, which will ever make his work popular, useful, and indis- pensable." Dr. Doddridge says,— " Henry is, perhaps, the only commentator so large that deserves to be entirely and attentively read through. The remarkable passages, I think, should be remarked. There is much to be learned from this work in a specu- lative, and still more in a practical way." Dr. Edward Williams says, — " It is an incomparable work, and too well known to need a discriminating character." 0 The Rev. Dr. Thomas Hartwell Home, in his valuable Introduction to the Study ofthe Scriptures, says, " that its high and generally known value is so just and exten- sive, that it needs no recommendation." The Rev. Adam Clarke, the Commentator, says, — " The Rev. Matthew Henry, a very eminent dissenting minister, is author of a very extensive Commentary on the Old and New Testaments, and one of the most popular works of the kind ever pub- lished. It is always orthodox, generally judicious, and truly pious and practical." Extract of a letter from the Rev. Francis Wayland, President of Brown University. " I am gratified to hear of your intention to present the religious public with an American edition of Henry's Commentary. I know of no work of the kind in any language which combines more sound good sense with fervent and deep-toned piety." 34 CONCHOLOGIST'S FIRST BOOK; OR, A SYSTEM OF TESTACEOTJS MALACHOLOCrY. Arranged expressly for the Use of Schools. With Coloured Illustrations of two hundred and fifteen Shells, presenting a correct type of Genus. A beautiful 12mo. vol. SEXTET'S MAXIMS. Law's Call. A SERIOUS CALL TO A B3EYOOT 111 H©IL¥ ILEFE. ADAPTED TO THE STATE AND CONDITION OF ALL ORDERS OF CHRISTIANS. By WM. LAW, A.M. Nineteenth edition, with some account ofthe Author. Confession of Faith. THE CONSTITUTION THE PRESBYTERIAN CHURCH IN THE UNITED STATES OF Etc., Etc., Etc. As ratified by the General Assembly, at their Session in May, 1821, and amended in 1833. SB=— DOTEIL SELECTION OF E7M1TS. TEE PSALMS OP DATID. | IN METRE. \ Translated and diligently compared with the Original Text, and former transla- ' tions; more plain, smooth, and agreeable to the text, than any heretofore. ; Allowed by the General Assembly of the Kirk of Scotland. 32mo. ^mm BRIBES Ig@©I£g OR, PRACTICAL FORMS FOR EVERY MAN OF BUSINESS. Containing Three Hundred ofthe most approved Precedents. By a Member ofthe Philadelphia Bar. GItEEK TESTAMENT, By WILSON. L.ES A VENTURES DE TEL,EMAQ,ITE F IL S D' tTX T S SE. Par M. FENELON. NOITVELLE EDITION, PAR M. CHAS>ri?rBRUN.'>v & :■££=- 36 ^ '■*■'".. ,>*.-ar i.-'' ••-..o>v ' . .^-. .-*': !;*< •ft'.'-■ r } . v* V . »• " ■•!"■'«'" »' ■ -r u, I 4 V ; • 'V ^ R%H,\: *3« .Vjfl .** t •; *?