the state of perfect apoplexy. This observation is confirmed by the present cases, and by daily experience, and hence it is that hemiplegia is seldom fatal in the first instance. We this day witnessed the examination of an elderly female, affected with hemiplegia after a fit unaccompanied by total loss of consciousness, in whom there were the remains of as many as five apoplectic extravasations more or less considerable. The immediate cause of her death was extensive serous effusion in and on the brain, and a latent or nearly latent peripneumony. The second proposition of our author runs :-that convulsive movements of the limbs may be absent in cases of serous effusion, and death may not be its necessary consequence.

CASE 3. Pitié Hospital, 1823. A man, ætat. 45, had for several years been affected with incomplete paralysis consisting of feeble contractility of the muscles, and occasional deafness. He was treated with some benefit and left the hospital in which he was, but two or three days afterwards having joined a drinking party he was seized with apoplexy, abandoned by his companions in the public streets, and not brought to La Pitié till the following day. At this time he was in a state of perfect coma and insensibility, without power of moving or sense of feeling in any of his limbs, which were not in the least contracted. The face was red, but not distorted. Antiphlogistics and derivatives succeeded in arousing him so far that he was able to relate his previous history, but gangrenous erysipelas of the leg supervened, and the patient died eighteen days after the apoplectic seizure. On dissection there was found a great quantity of serum between the arachnoid and pia mater and in the ventricles of the brain. The spinal arachnoid had been in a state of chronic inflammation, for from the 5th cervical vertebra to the 6th dorsal there were streaks of false membrane of a blackish colour, a reddish serum in the cavity of the arachnoid, and softening and injection of the spinal marrow in its anterior part.

If we compare the foregoing cases,

says our author, we must be struck with the following points of coincidence

Imo, the existence of a more or less ancient organic lesion; 2ndo, recent apoplectie symptoms; 3tio, alteration of the cerebral substance, with abundant serous effusion. In the two last cases the effusion was produced by disease of the medulla spinalis, was between the membranes and in the ventricles of the brain, and gave rise to general paralysis. In the first case, on the contrary, the palsy was confined to one side of the body and the effusion was into the opposite ventricle.

The third and last proposition of M. Bosc, asserts, that convulsive movements accompanying apoplectic symptoms, do not certainly indicate serous apoplexy; they only render its existence probable in so far as the individual is a paralytic.

CASE 4. Salpêtrière Hospital, 1829. A woman suddenly lost her consciousness, became paralytic on the right side and presented contractions and convulsions of the left arm to so violent a degree, that restraint was necessary. Bleedings, derivatives, &c. were employed but the patient died on the 5th day.

On dissection an apoplectic extravasation was found in the left optic thalamus and posterior part of the corpus striatum, from which it had penetrated the corresponding ventricle. The more fluid portions of the blood had passed through the foramen of Monro into the right ventricle in which it had accumulated. No other morbid appearances were discovered in the brain.

This case is an example of what not unfrequently occurs in apoplectic attacks, and in the artificial apoplexies produced by injuries of the head, we allude to palsy of one side and convulsive contractions of the other. The palsy is generally on the side opposed to the pressure on the brain, the contractions on the same as the latter. Several explanations of the fact have been given by authors, but none of them are very satisfactory. In the present instance M. Bosc attributes the phenomenon to the escape of the fluid parts

of the blood into the ventricle opposite to that in which the extravasation had taken place. After all, we are not convinced of the accuracy of the diagnostic symptoms of serous effusion, nor do we think it possible in some instances to distinguish during life between it and venous congestion. We are convinced, however, that serous effusion is a very frequent mode of terminating the lives of those who have laboured under palsy,

or any organic affections of the brain of a chronic character. Effusions into the head and latent peripneumony seem to us to be the general dénouement of the drama, in patients affected with irremediable, though not absolutely in themselves fatal maladies. It is for the purpose of putting this fact in a clearer light that we have thought it worth while to notice the present paper.

XIII.

BALTIMORE ALMS-HOUSE INFIR

MARY.

In No. VIII. of the American Journal of the Medical Sciences is a report of cases by Dr. Wright, physician to the above institution. We extract one or two of the more interesting.

I. LARYNGITIS.

CASE 1. Cynanche Laryngea :-"Samuel Morgan, aged forty-three, tall, spare person, florid countenance, light eyes and hair, admitted January 15th, 1829, suffering under the chronic consequences of what he termed a bad cold, contracted some weeks before. He was very hoarse, almost without distinct voice, short dry cough, not frequent, no pain in any part of the breast, no difficulty either in common breathing, or on making full inspiration. There was no fever in the general, though the patient before coming to the Alms-house, had laboured under an irregular intermittent, which still occasionally recurred. The pulse commonly small, without frequency, and soft, tongue clean, appetite moderate, bowels regular, evacuations of ordinary character, no evidences of gastric derangement. The main features of the case, in short, were made up of the peculiar hoarseness, dry cough, and considerable general debility; tracheitis, now chronic, with some bronchial con

cern, seemed the primary and still predominant affection, to which all the other symptoms, the general debility, and probably the intermittent also, held a dependent relation."

Under the use of alteratives internally, with counter-irritation over the top of the chest, the patient improved so far as to be able to leave the house in the second week in February.

"On the twenty-fourth of the same month, twelve days after being reported for work, I found Morgan again in the hospital. He was now acutely ill; his face flushed, of a purplish hue, countenance betraying great distress, breathing slow and difficult, often causing a struggle for breath, in which he would raise himself on the bed, throw his head back as far as possible, and bring into forcible action every muscle concerned in opening the chest for admission of air. Just before and after one of those severe struggles for inspiration, he made violent efforts to throw off masses of ropy mucus which seemed to fill the posterior fauces, and choke the passage of the larynx. The entrance and expulsion, particularly the former, of air through the larynx, was attended by a loud sound, of that peculiar rough, ringing character, sometimes called metallic, so eminently characteristic of extreme spasmodic or inflammatory narrowing of the apertures of the glottis and larynx. The act of swallowing was somewhat hindered and painful, though far less embarrassed than the respiration. The external aspect of the

throat, not less than other symptoms, shewed the character, and in some degree the extent, of the affection which had brought the unfortunate patient into so much distress and danger. The body of the larynx in front, with the corresponding portion of œsophagus behind, were swelled out into a globular form of much more volume than the natural state of the parts, the surface of the tumour, and the whole front of the neck, having the same dark red hue as the face, and the enlargement possessing great hardness and sensibility to the touch. The pulse was small, quick, and weak, having neither tension nor firmness. The report furnished by the resident students was, that the man had been brought into the ward the night preceding, with the symptoms just described, but of less intensity; that he was then chilly and depressed, and seemed incompetent to bear active treatment by direct depletion, but had been freely vomited, and had taken a mercurial cathartic."

The smallest-sized cupping-glasses were applied in quick succession to the seat of tumefaction, and a draught of infusion of seneca, tartrite of antimony, in small portions, oxymel of squills, and compound tincture of camphor exhibited at short intervals. The patient also inhaled the vapour of hot water in which chamomile and serpentaria had been infused, with great relief. When the cupping-glasses were removed the scarifications bled freely, and on the subsequent application of a blister the local hæmorrhage was rather considerable. The consequence of this free local depletion was complete relief to the swallowing and breathing, and after a few days cordial nourishment and light tonics were administered with the effect of producing a permanent cure.

CASE 2. Chronic Laryngitis.-Margaret M'Carthy, æt. 42, of robust constitution, admitted May 10th, 1827.

"Respiration sonorous, and somewhat laboured, but not painful; voice a hoarse whisper; no fever; cough occurring in paroxysms somewhat severe, without expectoration; pale countenance; not much emaciation; no

particular debility, nor other signs of general bad health. In February preceding, she had been attacked by symptoms of croup, as she reported, and was dangerously ill for many days. She recovered slowly, with the alteration of voice, embarrassed respiration, and cough, above described, which symptoms continued ever since, and had undergone occasional exasperation, by cold, fatigue, and other disturbing causes.

"The patient had been but a short time in the infirmary, before an acute attack of her disorder supervened. She had been out of the ward for a few hours in the day, and at night complained of feeling chilly and unwell; in the course of that night her breathing became difficult and painful, with a feeling of great stricture across the top of the thorax; inspiration was impeded, and soon became extremely laboured and anxious, attended by a loud and peculiarly harsh croaking sound, which was audible in every part of the hospital. A paroxysm of coughing occurred at intervals, and distressed the patient very much; it was abrupt, renewed rapidly for some seconds, and of a sharp thrilling kind, as of air forced with great impulse through a tense narrow passage. There was no expectoration, except that sometimes after great effort in coughing, a considerable quantity of colourless, ropy fluid would be suddenly thrown off, by an act of strong expiration, amounting nearly to vomiting. The patient's countenance was pale, and betrayed much distress. Pulse small, quick, and soft; temperature of the body rather low.

"The treatment of this severe påroxysm, consisted in the exhibition, at intervals, of the camphorated julep, with tinct. opii and æther; liberal demulcent drink, an epispastic to the thorax, and a light, warm cataplasm of flaxseed, chamomile, and spirit of camphor to the front of the neck, with bottles of hot water to the lower extremities. The symptoms of cynanche anginosa gradually passed off, and in 48 hours the patient was in her previons state, except some general debility. Paroxysms similar to the one just des

cribed were frequently renewed, commonly ensuing to some exposure or change of weather. In the course of three months she suffered not less than six or eight such attacks-usually of thirty-six or forty-eight hours' duration, -without any sensible impairment in the intervals of her general state of health; the paroxysms always breaking up with a discharge of large masses of uncoloured gelatinous matter. Great efforts were made to alter the state of parts which kept up the liability to those sudden attacks, with their train of terrible symptoms. The patient was put on a guarded mercurial course, small doses of calomel in combination with guaiacum and cicuta; with the employment, as liberally as possible, of tartarized ointment, over the upper region of the chest, and a succession of blisters kept open in front of the traehea; her diet was regulated, and bowels kept soluble. Once or twice her mouth was rendered slightly sore by the calomel, and during the continuance of that impression, the patient thought her breathing was much more free; but one or two severe seizures occur ring after what was considered a full trial of mercury, it was withdrawn altogether, and various means afterwards employed. The plan of counter-irritation was frequently renewed, and having sometimes procured great advantage from the steady exhibition of copaiba, in the atonic forms of bronchitis and catarrh, an emulsion of that article was employed in the present case after the mercurial alterative experiment was given up.

"While under the balsam course, with counter-irritation externally, the patient had less cough, enjoyed longer immunity from acute attacks, breathed better, and was in many respects more comfortable; but still her voice was rough and stifled, and slight impressions of cold or damp brought on some degree of that harsh, stridulous, croaking kind of inspiration, which became so exalted and predominant in the severer paroxysms. On one occasion, when this woman had been in the yard of the alms-house, after a day of cold rain in August, she was affected at night with

the usual symptoms of a suffocative attack. In this instance, the bad symptoms exceeded their common intensity; the usual palliatives, diligently applied, failed to give relief, and the patient expired suddenly, in twelve hours from the incursion of the paroxysm.

"Examination, Eight Hours after Death.-Along the anterior surface of the trachea, somewhat on its left side were a number, five or six, round bodies, from the size of a pea to that of a marble, lying loosely. Those bodies were of dark colour, part quite black; from their place and manner of distribution, they appeared to be the external bronchial glands degenerated. They were of soft pulpy consistence, the black bodies of the same colour within as on the outer surface. At the great division of the trachea, directly in the bronchial angle externally, appeared a round body, of dark red colour and considerable magnitude, about the size of an English walnut, the mass was dissected out, and felt firm and heavy. On attempting to cut through the middle of the body, its complete division was prevented by the resistance of a hard substance within, and a partial section only made. The body now presented a three-fold_constitution; the external matter, for a quarter of an inch was dark red, then a layer of greater thickness, quite black, while the centre of the body was a hard, white, calcareous substance, supposed to weigh one drachm. The whole mass, like the bodies along the line of the trachea, seemed to be a morbid enlargement and conversion of the small glands usually occupying the external bronchial angle.

"The interior of the trachea was very pale, except just before its branching, where there was a florid patch, an inch in extent. The inner surface of the rest of the tube, up to the thyroid space, was not only without colour, but its mucous membrane so thin that it could not be certainly distinguished, and the cartilages seemed without any regular interior covering; nothing of the sort appearing, except a few filaments stretching across from one ring to another; yet there were no marks of distinct ulcerous waste in any part of