[The writer then gives two cases illustrating the plan of treatment pursued. Of these we reprint the first.]

Kublee, sepoy, aged about 25, was admitted May 22nd, 1866, at 10 a. m.. complaining that he had much pain in the stomach, and saying that he had been purged three or four times during the previous evening, and that vomiting of white fluid had come on in the night. Pulse small and quick; anxious expression of face. He was ordered to have immediately fifteen minims of chloroform, ten minims of tincture of opium, and a drachm of spirit, in an ounce of water; and to have a mustard poultice applied. I was then called by the native doctor, and found that for the time the vomiting had abated; the pulse was very small and quick. He was ordered to have five grains of calomel immediately; and the following drink every hour, or more frequently, in ounce doses.

B. Potass. chlorat. 3j; acidi hydrochlorici fort. viij; acidi nitrici dilut· 3iss; aquæ 3xxiv. M.

During the next four or five hours, he was purged two or three times, all rice-water evacuations. I saw him again at 3.30 p.m. He was collapsed; the eyes were sunken; the skin cold, but no sweating; the pulse barely perceptible, and that only at intervals. The voice was choleraic. He was ordered to repeat the calomel and chloroform, without the tincture of opium. At four p. m., I gave half an ounce of arrack in water, which was immediately vomited. He was ordered to have an ounce of Liebig's cold soup every half hour; and to continue the chlorate of potass drink. No raw meat could be procured, but a quantity of the soup was made from a freshly killed fowl, and he had the first dose about 5 p.m. At 6, I saw him again. No vomiting or purging; pulse markedly improved: skin warmer.

The soup was first given in 1860, in consultation with Dr. Ogilvy, then of Her Majesty's 33rd Regiment, whose remark as to its probable action was to the effect it seemed to supply to the blood what was removed by the purging. This, after careful consideration, I still think is the correct explanation. I would not wish to enter into any discussion in these short notes as to the pathology of collapse; but it will be seen I cannot altogether agree with Dr. G. Johnson's argument, able though it be. I think that the cases of sudden collapse, with little vomiting and little or no purging, admit of a different interpretation to what he has assigned.

The soup was made by placing eight or ten ounces of finely minced raw meat in one pint of cold water, to which eight drops of strong muriatic acid had been added, stirring with a bit of stick occasionally for ten minutes, and then straining. The soup will only keep good a few hours; but if a supply of lean meat be kept ready minced, it can be made almost as wanted. Salt should always be added.

Hitherto I have only given the soup when collapse was established: now I should be inclined to give it in any case where diarrhoea is accompanied with a failing pulse, and most assuredly when the characteristic discharges of cholera have come on.

I believe that at first, especially in collapse, the soup should be administered in small, but frequently repeated, doses. I generally give an ounce or two every hour, or sometimes every half hour, alternating it with the chlorate of potass drink. Water, cold or iced, in small quantities.-Brit. Medical Journal, Aug. 29, 1868, p. 216.

DISEASES OF THE NERVOUS SYSTEM.

11.-ON INFLAMMATION OF THE BRAIN, INCLUDING SOFTENING AND MENINGITIS.

By Dr. SAMUEL WILKS, Physician to, and Lecturer on the Practice of Medicine at, Guy's Hospital.

[It must be self-evident that inflammation of the brain cannot be treated after the simple manner of inflammation of the lungs; for in so complex an organ LVIII.-3.

as the brain the symptoms must vary immensely with the part affected, as also with the cause.]

As one of the chief results of inflammation is softening, and as this may arise under a variety of circumstances, I think it will be as well to allude to this first. Softening or ramollissement, if you prefer the French term—is used in a very vague manner. Generally, when we say softening is present, we mean a chronic change has taken place in the brain substance, whereby it has become disintegrated, and its function lost. But softening, as a result of inflammation, may be acute, and be developed in a few days. Such a case we ought not to designate by the name of softening, but by that of cerebritis or encephalitis. In all acute inflammations the tissues become soft, but we should not therefore style the disease by one of its effects. We should not, for example, call pneumonia a case of softening of the lung. In the case of the brain, however, we are often compelled to speak of the result as if it were the disease itself, being altogether ignorant of the cause not only during life, but even after death, a doubt even then existing whether the softening be due to inflammation or be the result of a chronic disintegration from a change of nutrition. Then, again, besides these actual and tangible forms of softening, we are using the term in the vaguest possible sense, as applicable to a great variety of symptoms. Thus, when a person becomes a little feeble in his mind, and has some slight paralytic symptoms, we often say the patient has softening of the brain, intending only to express that some impairment has taken place in the cerebral structure, and not necessarily a change like that of softening, which is visible to the naked eye.

There are, no doubt, a large number of changes going on in the living brain whose effects are at once perceptible by some alteration in the working of the machine, expressed by some physical or mental failing, and which in any other organ would not be manifest. A slight structural change, for example, in the liver would not be apparent except perhaps by some general feeling of malaise, but in the brain this would at once evince itself. What these changes are, and how associated with distinct symptoms, we have yet to learn. I hear sometimes the remark made that morbid anatomy has taught us enough, and that all we want is some medical philosopher to arise to generalize from our facts and supply us with theories; but I think I am in a position to say that our facts are meagre or scanty, and that we are only in the infancy of the science of cerebral disease.

As regards this softening-this tangible softening, with its evident symptoms-we have been in the habit of expressing the difference between a chronic softening resulting from decay or degeneration and that arising from inflammation, and styling these white and red softening. You are familiar with the terms red softening as denoting inflammatory, and white as meaning a more passive or atrophic change. If, however, red softening does result from inflammation, then it would be more desirable to at once designate it inflammation of the substance of the brain, or cerebritis, or encephalitis; but the reason, as I before said, why we cannot do this is that it is only in exceptional cases that this inflammatory process is evident as an acute and idiopathic process, and thus we are obliged to speak only of the effects. In the majority of cases the softening is chronic and associated with other disorders. If the softening be of a red colour, we call it inflammatory, the redness being due to the greater vascularity. We are influenced also in our decision by the age of the patient, and by the circumstances connected with the illness. In older persons, and especially where the arteries are diseased, as in morbus Brightii, we expect to find rather the white or non-inflammatory softening.

Suppose we make a post-mortem examination and find softening, how does it display itself? In some cases, when you make a section through the organ, you see the hemisphere presenting a peculiar appearance in the medullary matter; a certain portion. more or less circumscribed, looks and feels pulpy, resembling somewhat a piece of blanc-mange. As a rule, however, it does not look thus smooth, but is disintegrated, and thus, if a section be made, it shows a broken surface. When you pass the knife through the substance,

sticks to the knife, and if you stir it about you can make it into a pulp or ste. If merely a number of softened spots were present, these would be parent, when you made the section, by an equivalent number of broken irfaces.

If the softening has proceeded a stage further, then the brain matter may e quite broken up, or be semi-fluid, and a portion of this running off, a deression is left. If a stream of water be allowed to trickle upon it, the brain uatter may be washed away, and a distinct hole be left corresponding to the softened part. Sometimes even during life a disintegration and absorption occurs, so that, when you make a section of the hemisphere, you find a large hollow space filled with a fluid like lime-water and the débris of brain substance. All these cases where there is actual loss of substance come under the category of cases of white softening. They arise in connexion with diseased vessels and general decay. In the red or inflammatory softening the disintegration is not so great. Besides these two kinds, some authors have spoken of a yellow softening, which they surmise to be of a peculiar kind, and due to a chemical change going on in the fatty acids of the brain. In some of the best-marked cases, however, which I have witnessed, I have considered that the yellowness is due merely to an altered condition of the colouring matter of the blood which has been present in it.

So

Then again, showing how difficult it is to decide by the mere colour whether the softening is inflammatory or not, if we take the case of acute hydrocephalus or tubercular meningitis, we know that there is an inflammatory exudation into the ventricles, and that the central parts have undergone a remarkable softening; the septum lucidum and fornix and adjacent parts are broken down and diffluent, but they are perfectly white-milky white. marked is this that those who maintain that a structure must be red to indicate inflammation would say that this central softening of acute hydrocephalus was due to a simple death or atrophy of the part, or had occurred from presence of so much fluid, which had, as it were, melted it down. Of this there is no proof, but, on the contrary, that the change is inflammatory. You no doubt might think that the microscope would positively inform us as to whether a softening was inflammatory or not, but I am sorry to say it does not do much for us in this respect; for when the cerebral structure is broken up, and a number of new products are present, it is extremely difficult to say whether inflammation has anything to do with the process or not. The microscope is extremely useful in proving the fact of softening, because, besides the broken nerve tubules, it displays a quantity of new formations, as granule masses, which, to say the least of them, are morbid. It often happens that we wish to know whether a part of the brain has undergone a morbid softening or not, and by using the microscope and finding these bodies we are sure of the fact.

Softening is most commonly localised, whether it be due to an acute or chronic cause, but occasionally we find large portions of the cerebral structures affected. In cases where there is much disease of the blood-vessels, spots of softened tissue may be found throughout the whole brain, and in the much rarer cases of acute encephalitis, nearly the whole cerebral structure may be found to be undergoing disintegration. In cases of this kind, destruction of so large a part of an important organ will of necessity very speedily bring about a fatal issue, but in instances of local inflammation and softening, life may be prolonged for many months, and ulterior changes result; one of the commonest is for the brain tissue to perish until a mere vacuity is left, containing a whitish fluid with remnants of blood-vessels. In some cases this cavity is lined by a smooth and tolerably thick membrane. Should the inflammatory process proceed to the stage of suppuration, then an abscess is formed. This may or may not be contained in a cyst. The latter, under these circumstances, is not merely a thin delicate membrane, but is a thick, firm bag, composed of tough lymph. A very important question, whether idiopathic inflammation of the brain ever ends in suppuration, you have heard discussed on other occasions-whether, indeed, a cerebral abscess does not signify either that the morbid process has been set up in the bones,

or that it is pyæmic. The question has a very wide pathological signification, referring as it does to the mode in which the various tissues of the body undergo their own peculiar modification in disease. It was the question which above all was most interesting to me when I reluctantly retired from the office of demonstrator of morbid anatomy; for after an experience of many years I could not but observe that the character of the tissues was as potent in the form which the morbid product assumed, as the supposed vice in the blood or constitution. For instance, it is said that cancer and tubercle are distinct elementary productions which may arise indiscriminately throughout every part of the body. Such is a prevailing idea, but not founded in fact, as I could show you did time and place allow; and, as regards suppuration, the same opinion is held. You are by this time aware that the old doctrine of inflammation and its various stages was taught by the Professors of Surgery, who took, as a type, the inflammation of the skin or cellular tissues, in which the different processes of lymph production-suppuration and gangrene-could be visibly followed. So strongly imbued were all with this doctrine of inflammation that it was denied that some organs could be the subject of it, as, for example, there was no such disorder as gastritis, because lymph was not found on the surface of the stomach, or an abscess in its walls. We are now learning that the morbid changes take place in the cell structures of the organs and tissues, and that each of these undergoes its own necessarily peculiar alterations in disease.-Medical Times and Gazette, June 13. 1868, p. 627.

12.-ON DISEASE OF THE SPINAL CORD.

by Dr. SAMUEL WILKS, Physician to, and Lecturer on the Practice of Medicine at, Guy's Hospital. The true interpretation of pain in spinal disease is one of the most important matters to understand. In the first place it is undoubtedly true that the spinal cord may be diseased throughout its entire thickness without the patient experiencing any pain, and without indeed there being the slightest sign of shrinking when the back is struck. On the other hand, the most intense spinal pains are those which are caused by disease involving the nerves only, as in aneurisms, which corrode the spine and leave the cord itself untouched. Again, it has been found that in those cases of meningitis of the cord where pains in the limbs have been a constant symptom the roots of the nerves have been involved in the process. With these facts before us we have some general rules to guide us in the interpretation of pain, although I could not positively teach you that pain necessarily implied an implication of the roots of the nerve external to the cord. It is highly probable that to a certain extent an implication of the nerve-fibres within the cord may produce the same result, but pain is not a necessary consequence, I am sure. We may note also that the irritation of the nerve roots not only produces pain and excites the centres to corresponding movements, but also causes tonic spasm or rigidity. Thus, when the membranes are affected in common with the roots of the nerves, this rigidity may often be observed. I have seen a man who, having fractured and dislocated his spine in the upper dorsal region, had intense pain and rigidity of the arms, but as soon as the bones were replaced the pain and spasm passed off. In chronic inflammation of the membranes of the cord the surface of the medulla is generally involved, and thus there may be more or less paraplegia; should the disease at one spot have involved the entire thickness of the cord, then sensation is lost, but the excito-motor function in the part below may be more than usually exalted. on our museum is the spinal cord of a man showing great thickness and ossification of the membranes, closely adherent and bound up with the structure of the cord. This man lay quite paralysed, but his spinal centres were in the highest state of tension, so that it was painful to pass by his bed; the merest touch made his whole body quiver, the act of micturition threw him into convulsions, and, I believe, on one occasion a jar against his bed caused him to spring on to the floor. He was in the condition of a tetanised frog.

Let us see how these observations apply to cases before us, as, for instance, the case of the boy who was lately lying in Stephen Ward with disease of the dorsal vertebræ. His back projected outwards in consequence of an angular curvature, and thus, no doubt, a quantity of inflammatory or purulent material existed within the canal pressing on the medulla; and what might you think would be the result? You would suspect that he would be lying in bed with his legs stretched out, and quite paralysed as regards motion. The pressure not having reached the centre of the cord, you might think that sensation remained; also, as a pressure of this kind on the upper part of the spinal cord would involve the motor tract but leave the sensory entire, and as the medulla would be healthy below, that the true excito-motory function would remain. Thus you would expect that, although he would be perfectly helpless to move in the slightest degree, a tickling of the feet would cause a drawing up of the legs and their flexion on the body. You might also have expected from the membranes being involved, and consequently the existence of an irritation of the cord through the roots of the nerves, that there would have been some convulsive movements of the legs or rigidity. Now all these symptoms were actually present, and considering what, in all probability, was the nature of the case, you will see how they accord with all wellobserved physiological and pathological facts.

Thus far, I think, is pretty clear; in some cases of spine disease we may find motion lost only, in others sensation only, or the two together. Then again, although the conducting power of the cord is lost, and with it a paralysis of sensation and motion, its true function may remain, for the former may be destroyed by the most limited layer of disease, supposing it involve the whole thickness of the organ, but let the cord itself below be destroyed, and then the excito-motor has also vanished. But is this all? Has the spinal cord, or the nerves proceeding from it, any other functions? It is thought by many that they have, and thus it is necessary to suppose that a nerve is a vastly more compound organ than was once supposed-that it contains filaments destined for special functions. It has been thought that the fibres which conduct impressions to the spine and those which reflect movements back again are different from the fibres which convey sensations to the brain and from those which carry down the dictates to the muscles. Of this division, however, there is no proof. Then, again, as I shall have presently to show you, there are some who think the muscles have their own sensory nerves, and that we are endowed with a true muscular sense. Again comes the important question, and one of the most vexed questions in nervous physiology and pathology, whether any influence is conveyed along the cord which involves the nutrition of the tissues, or whether the power which the nerves possess in this respect is derived from the sympathetic system.

But this is not all, for it is said that what we call common sensation may be divided into different varieties. I have not Brown Séquard's lectures at hand, but I think I am right in saying that this physiologist states that there is one sense for touch, and another for the appreciation of temperature, another for such a sensation as would result from pinching or pain, and another for tickling. I could say from my own observation that I have seen a patient who was insensible as regards touch, yet appreciate a difference of temperature. Also it may be constantly observed that hysterical women, who make no complaint of inability to feel any object, yet will often allow needles to be thrust into them with impunity, and sometimes even have lost all power of judging of temperature. I believe Dr. Darwin many years ago separated sensations of heat and cold from those of touch and pain. In mentioning the name of the first distinguished physiologist, I might inform you that it is his opinion that every function of the nerves which appears distinct must have its appropriate filament, and thus he considers that every ordinary nerve contains fibres of eleven different kinds.

There are, first, the fibres which conduct sensory impressions, and then the conductors of motor influence. These are of two kinds-those which pass to and from the sensorium, and those which are connected with the spinal cord for the reflex or excito-motor actions. Then again there are fila