system: 2dly, Those which secondarily affect it through the sensorium: 3dly, Through the ganglionic system. Blows on the head or neck, causing a contrecoup, which shall either structurally injure or functionally disorder the medulla, occasionally give rise to chorea, not only at the time of their occurrence, but at uncertain periods afterwards: so also injury of the spinal marrow, by direct compression; alteration of its structure by rheumatism; and perhaps its irritation, by certain injurious practices;-the irritation of the incident nerves, by a wound, by the poison of mercury, of lead, of strichnine, and by skin diseases. Of those causes which act primarily on the sensorium, by far the most frequent is an affection of the mind, arising from any of the depressing passions; as from sudden fear, from horror, from grief. Perhaps, however, these causes should be rather considered as of the first kind, if the theory be adopted, that the seat of emotion is in the upper part of the spinal cord, and not in the brain. Other causes more evidently first affect the sensorium; as, organic diseases of the brain, fever, epilepsy, hysteria, and mental alienation. Of those causes which act primarily on the ganglionic system, may be enumerated, costiveness of bowels, with morbid accumulations in them, and worms of different kinds. Rheumatism also, when it affects the heart and pericardium, may give rise to the disease, through the irritation of the plexus and ganglia, which so entirely surround that organ, and the origin of its great vessels: and irregular mentruation may produce a like effect, through the lumbar plexus.

In a note we find the connexion between chorea and cardiac affections noticed still more pointedly. We transcribe the note in question.

"Out of a very large number of cases of chorea, seen lately by my friend and colleague, Dr. Addison, to whom I am indebted for having first directed my attention to this point, only two have been without a decided mitral or left ventricular bruit. In these two there was diseased heart; and in one case, examined after death, there was found old thickening of the mitral valve, with very recent pericarditis. Should further investigation prove chorea to me more immediately dependent on disease of the heart or pericardium, than has been hitherto supposed, the merit of the discovery will certainly be due to Dr. Addison." But we cannot help suspecting it will turn out otherwise.

Dr. Babington relates twenty-five cases, none of which require notice. The gist of the matter-the treatment, is thus handled.

He has not found any one remedy so superior in efficacy to the rest, as to induce him to abandon all others in its favour. On the contrary, the most powerful will sometimes disappoint our expectations; and we are then obliged to try one after another; and in the end, perhaps, remain uncertain, should the patient do well, whether the recovery is to be attributed to the means employed, or to the power of Nature herself. Dr. Babington, therefore, treats the cases rationally.

Where there is evidence of congestion in the head, marked by giddiness and headache, occurring in subjects of a full habit and florid countenance, the treatment should be commenced with moderate depletion; which, however, it would be more advisable to effect by leeches or cupping-glasses, than by the use of the lancet; and these should be applied to the nape of the neck, or behind the ears. Attention to the state of the bowels is of course, in all cases, indispensable, even though the general treatment should be of a tonic character: but wherever there is reason to suspect that the symptoms are dependent on a constipated or loaded state of the bowels, or their irritation from the existence of unwholesome aliment, purgatives should be administered freely and frequently; and those of the more active kind should be employed. As this state of the prima via exists in a great many cases, it is not difficult to understand why the purgative plan of treatment has proved frequently successful. Where worms, and especially tenia, cause the irritation, turpentine, and other anthelmintics, will prove most successful; and No. 87. 22

these cases also will swell the list of those who will be benefitted by brisk and repeated purgatives.

Where there is reason to think that the disease is connected with the state of the uterus, occurring about the period when the catamenia should appear, and combined with symptoms of hysteria, those remedies will naturally suggest themselves which have a special power in causing this discharge, in obviating its irregularity, and in correcting its unhealthy character. The state of the teeth should also be looked to about the period of the second dentition; and even on the cutting of the dentes sapientiæ, as a probable source of irritation;—and the gums should be lanced, or the decayed roots of the first set removed, according to

circumstances.

Where the disease has arisen from a metastasis of rheumatism to the fibrous structure of the theca of the cord, it ought to be treated in the same way as pericarditis, by depletion, general or local, antiphlogistics, and the employment of mercury, carried to slight salivation.

The following are Dr. Babington's opinion on the subject and comparative value of tonics.

"In a very numerous class of cases which owe their origin to sudden emotion, producing a strong impression upon a weak and excitable nervous system, the patient will be most benefited by all those remedies which improve the general health, and give vigour and tone to the nervous and muscular systems. The most severe case I ever saw recover, was cured in a few days by divided doses of port-wine, in which enough of sliced rhubarb was steeped to render it gently aperient. Various vegetable tonics have had their advocates; but bark and sulphate of quinine may be taken to represent them all. The metallic salts and oxides have, however, of late years, been generally preferred. Sesqui-oxide and sulphate of iron, sulphate of copper, oxide and sulpate of zinc, nitrate of silver, and arsenite of potassa, have all been tried, and found, in different hands to succeed. The testimonies in favour of sesqui-oxide of iron in large doses, and of sulphate of zinc, are perhaps the strongest. On the latter remedy I have gener. ally, in the cases which I have just alluded to, most relied: and my expectations regarding its efficacy have seldom been disappointed. I have found it necessary to administer much larger doses, however, than are usually given; good effects seldom being perceptible until twelve or fourteen grains are taken three times a-day. By gradually increasing the quantity a single grain at a time, even much larger doses than this may generally be employed, without exciting sickness, and with the best effect. I have known half-drachm doses, thrice a day, taken for several weeks in succession.

Sulphate of zinc, however, will not be borne by all stomachs, even in small doses; and we are then obliged to give up its employment, long before we have attained even the minimum dose requisite to give it a fair chance of controlling the disease. In such cases, I generally have recourse to the liquor potassæ arsenitis, cautiously increased in its dose from three to twelve or fifteen minims, according to the age and strength of the patient, and other concomitant circumstances. I believe this is the most powerful remedy of all-at least I have found it so, in several obstinate cases; but I am deterred from employing it, where other remedies will succeed, from the sickness and griping pains which it is apt to cause, and from some fear that the constitution may be permanently injured by its continued employment.

As an external remedy, the shower-bath may be very often advantageously used, in conjunction with internal means; and I have even tested its efficacy with success, when used alone. In St. Petersburg, I am informed by a Russian physician, a new practice has, within the last year, been adopted with eminent success in obstinate cases of chorea. The patient is placed in a bath as hot as he can bear it; kept there for half-an-hour; and, when thus thrown into the most profuse perspiration, is suddenly plunged into cold water.-I have not

ventured to try this method of producing a sudden shock; or rather, I should say that opportunity has been wanting, since I have been made acquainted with it; but in an extreme case, and when other remedies had failed, I should, on the testimony I have received in its favour, not hesitate to employ it.

The treatment by electricity is very advantageously revived at Guy's Hospital. We have given an account of Dr. Golding Bird's paper upon this subject.

BALTIMORE HOSPITAL.

REPORT OF CASES TREATED IN THE HOSPITAL. By SAMUEL ANNAN, M.D. Senior Physician to the Institution.*

From amongst the cases reported by Dr. Annan, we shall select one or two.

CASE 1.-Paralysis of the Left Side of the Trunk and Extremities, and of the Right Side of the Face.-S. G., ætat. 23, negro, admitted April 7th, died June 5, 1840. On the 14th of May, 1839, while engaged in washing, was suddenly seized with an acute pain of the right side of the head, and fell down in a state of insensibility, in which state she remained during twenty-four hours. When she recovered her senses, she found she had entirely lost the power of moving her left arm, and in a great degree that of moving the leg of the same side. The right side was unaffected, with the exception of the face, the muscles of which had become paralyzed; those of the left side of the face still retained their accustomed power of motion; when her tongue was thrust out, it inclined very much to the right side; the sensibility of the left side was destroyed, and likewise that of the right side of the face; she could not hear with the right ear. The right eye became inflamed several weeks before her death, and the cornea was slightly ulcerated; the upper eyelid was constantly raised. When she attempted to speak her muttering was scarcely intelligible; paralysis of all the parts affected was complete; deglutition and mastication were performed with great difficulty.

Dissection twelve hours after Death. Brain.-There was venous congestion of the surface, and of the medullary centres of the hemispheres of the cerebrum. There was a fibrous, semi-cartilaginous tumor on the right side of the tuber annulare and medulla oblongata, seated in the substance of the dura mater, arachnoid membranes and the pia mater. It extended from the point where the fifth pair of nerves arises from the tuber annulare, covered the origin of this nerve and the whole of the right side of the tuber below this, and passed down along two-thirds of the medulla oblongata, and adhered to the right side of the basilar artery. The right vertebral artery was enclosed in the substance of the tumor. It was about two inches long. The surface of the root of the right crus cerebelli, on which it pressed, was softened, as was also that part of the tuber annulare, on which it lay. It was incorporated with the substance of the right side of the medulla oblongata, and had produced softening as far as it reached. This softening extended through the posterior tract, but became less as it approached the posterior surface. The anterior tract was a pulpy mass. Neither the anterior nor the posterior tract of the left side was perceptibly affected. The tumor pressed upon, and had caused softening of the roots of the fifth, seventh, eigth and ninth pairs of nerves. The bone was rough about the foramen lacerum posterius, and the condyloideum anterius. The liver was of a yellow colour.

American Journal, Med. Sciences, July, 1841.

The remarks of Dr. Annan are physiologically just and instructive. "The symptoms," he observes, "in the case given above, correspond very exactly with the seat and extent of the disease. The right side of the medulla oblongata was softened to the extent of complete disorganization. There was complete paralysis of both motion and sensation on the left side. The decussation of the fibres of the corpora pyramidalia, explains the loss of motion of the opposite side; but as we have no facts proving a similar interlacement of the fibres of the posterior or sensory tract, it is not so easy to discover how it happened that the right side was not deprived of sensation. Motion and sensation were unimpaired in the extremities of the side diseased; they were both destroyed in the same parts of the opposite or left side. Are we not justified, from this, in making the inference, that there is a decussation of the filaments of sensation, as well as those of motion?

The fifth pair of nerves is formed, on each side, of two sets of filaments, viz., one for motion, the other for sensation. The former take their origin from the intercebral commissure, which lies between the cerebrum and cerebellum, and is composed, in part, of the valve of Vieussens; while the latter can be traced down the posterior columns of the spinal cord, about an inch and a half below the tuber annulare. They were both pressed upon, by the upper part of the tumor, at the point of their emergence from the tuber, and the sensory portion, was involved in the general destruction of the texture of the medulla oblongata. The motory filaments being distributed to the muscles concerned in the motions of mastication, viz., the masseter, temporal, pterygoid, and buccinator, and those of the right side being paralysed, the power of masticating food was consequently rendered imperfect. The sensory portion, distributing its filaments to the mucous membrane of the nose, of the palate, the pulpy structure of the teeth in both jaws, the papillæ of the tongue, many parts contained within the orbit, the lachrymal apparatus, the conjunctiva, &c. and the skin covering the face, all these parts were necessarily deprived of sensibility. The seventh pair, formed under the old division of the facial and auditory nerves, or of the portio dura and portio mollis, is attached to the medulla oblongata, between the corpus py ramidale and olivare, just below the pons Varolii, and was involved in the disorganized mass. The facial nerve supplies the muscles of the face. including the orbicularis palpebrarum. The paralysis of this muscle prevented the closure of the eyelids; and the consequent exposure of the eye to particles of dust contained in the air, with the diminished sensibility of the conjunctiva, from the paralysis of the sensory portion of the fifth pair, the eye not feeling the irritation, of course no tears were secreted to wash out the irritating matter, explains the inflammation of the conjunctiva with ulceration of the cornea. The auditory nerve being destroyed, there was deafness of that ear. The glosso-pharyngeal, par vagum, and spinal accessory nerves, were all destroyed. The first supplies the muscles of the pharynx and tongue: the second distributes motor filaments to the larynx, furnishing the muscles concerned in the production of vocal sounds with motory power. The ninth, or lingual nerve, was likewise included in the disorganized mass. It goes to the muscles of the tongue, and also to those of the os hyoides. The muscles of the larynx and tongue of one side, having thus lost their power of motion, speech and deglutition were rendered imperfect. The genio-hyo-glossus of the opposite side, retaining its power of acting under the will, pushed the tongue to the right side when it was thrust We thus have a satisfactory explanation of the whole extent of the paralytic affection."

out.

CASE 2.-Pleura Pneumonia.-Pneumo Thorax-Gangrene of the Lungs.— M. R. ætat 19, admitted May 2nd-died May 3rd, 1840. This girl was a prostitute, and the persons who brought her to the institution, said she had been ill two weeks; she was delirious, and incapable of giving any account of herself;

she had been attended by a physician, but no information as to the treatment adopted could be procured; she was very restless, and was constantly talking and groaning: the skin and white of the eyes were of a bright yellow colour; tongue dry, and coated with a yellowish brown fur; teeth covered with dark brown sordes; respiration frequent, but not laborious; pulse 120, and of tolerable strength: there was general dulness of the chest, on percussion, with feeble respiration. Eight ounces of blood were taken from her arm, and she was ordered two grains of calomel every two hours until it purged. Early the next morning, her breathing suddenly became very laborious, and in the afternoon was extremely so accompanied by great heaving of the chest; pulse 120, full, but compressible. She was ordered infusion of serpentaria, with camphor julep; she died that night.

Dissection, 12 hours after death.-Brain.-There was great congestion of the large veins of the surface of the hemispheres, and numerous, and large red points were visible, on slicing the medullary substance. Thorax.-On cutting into the left cavity of the chest, air rushed out with a whizzing noise. The left lung was pressed close to the spine, and was of a dark brown, and in spots, of a black colour, and had a coating of dark brown lymph, tinged with yellow, over nearly its whole surface. Eight or ten spots, some as large as a walnut, were in a state of sphacelus; and were reduced to a black, soft, pulpy mass. These, when cut into, gave out a very fetid gas. The pleura had given way over one of them, and air had escaped; the larger part of this lung was hepatized. The bronchial tubes were of a dark red colour. The right lung presented the same appearances, but in a less degree. Only two or three spots were gangrenous, and hepatization had not advanced so far. Abdomen.-The mucous coat of the stomach was considerably congested. That of the small intestines in a slight degree; the other viscera were normal.

Dr. Annan remarks:-"This case which I have just narrated, is remarkable for the extent of the disease, and the occurrence of hepatization between the gangrenous spots. Both lungs would appear to have been very generally affected with pneumonic inflammation, which being improperly treated, and the constitution having been greatly debilitated by previous excesses, it passed rapidly into gangrene. Hepatization took place over all the spaces between the gangrenous spots. If the vital powers had not been so greatly impaired by a long course of dissipation, the pneumonia would have passed on to its ordinary third stage, viz. purulent infiltration. There would appear not to have been sufficient energy to elaborate pus. It is surprising, too, that there was neither cough nor expectoration. The delirium was the prominent symptom, which made me suppose that the brain was the organ chiefly implicated. Dissection showed congestion of the brain, but not in sufficient degree to have proved fatal. If, instead of exhibiting incoherent muttering and groaning as the prominent symptoms, she had been harassed with incessant cough, accompanied by fætid expectoration, the case would have been plain enough. As it was, the attention was drawn off from the lungs to the brain. It should, however, be remembered, that fætor of the sputa alone, is not pathognomic of gangrene of the lungs. It is true, that the breath and sputa are, in this disease, from the first, nearly as offensive as when the fætor becomes of the true gangrenous character. This is owing to the depraved condition both of the fluids and solids. But it is well known, that this state of things often occurs where gangrene of the lungs does not exist." No doubt too great importance has been assigned to fator of the sputa as a characteristic sign of gangrene of the lungs. But if, in addition to this fætor, the sputa are observed to be bloody, brownish, or greenish-something like the discharge from a sloughing part; and when any thing like green fragments of lymph are seen, together with a weak pulse, an elongated countenance, and a cadaverous aspect; in short, when the patient is in a state in which we