they command receive their power of action. Blood effused into the third ventricle from rupture of vessels of the thalami, or corpora striata, gradually finds its way down to the medulla oblongata, and is then speedily fatal. (Solly, p. 371.)

2. Effusion into the pons varolii produces paralysis of one or both limbs, according to its extent; but, after the first effect of the effusion. is over, it does not effect the intellect, as the lesion does not extend to the hemispherical ganglion. As the effused blood advances towards the medulla the organs concerned in respiration are more and more affected: first the muscles of respiration are irregularly stimulated, and the sensibilities of the respiratory passages become increased; at length the exaltation is succeeded by paralysis, and the patient dies from suffocation.

3. Effusion into the crus cerebri produces paralysis of the extremities on the opposite side of the body, and often of the opposite eye, from its affecting the optic nerve without interfering with the mental faculties.

4. Effusion into the corpus striatum is invariably followed by paralysis, (Morgagni.) In persons who have died after paralysis of long duration these bodies are always greatly changed, and the stria nearly obliterated. The paralysis is always observed in the extremities of the side opposite to that in which the lesion occurs. So long as the extravasation is confined to this part of the brain, and does not extend to the convolutions, the mind remains unaffected. (Solly, p. 375.)

The connexion between the extravasation in one side of the brain and hemiplegia of the opposite side of the body has been demonstrated by an immense number of observations and dissections. M. Serres, who had proposed to himself to solve the problem of determining the seat of effusion in any given case of apoplexy, examined the brains. of one hundred and seventy-one persons who died of cerebral apoplexy attended with paralysis of one side, found in every instance the lesion in the brain on the side opposite to that in which the hemiplegia appeared. He dissected forty-seven hemiplegic subjects who died at the Hospital le Pitié," and forty-seven times found disorganization of the brain opposite to the paralyzed side. In one hundred brains received from Salpetrie, Bicetre, and Hotel Dieu, the alteration of the brain was always, without exception, on the opposite side. To these we may add two or three thousand cases contained in the annals of science." (Serres New Division of Apoplexies. Phil. Med. Journal, Nov. 1824.)

5. Injury of the Thalamus Nervi Optici.-This part of the brain is seldom injured without paralysis of some part. In some cases there have been loss of motion when sensation continued perfect. In other

cases, loss of both sensation and motion of both extremities on the side opposite to the injured part are the only peculiar symptoms. In none of these cases was the mind injured.

6. Effusion confined to the Tubular Substance of the Hemis pheres.-After the first effect of effusion is passed, the intellect remains intact or only slightly disturbed, though loss of consciousness may remain for some hours.

In many cases the extreme symptoms of apoplexy leave little oppor tunity to distinguish the precise part of the brain which is the seat of the invasion, as the violence of the attack shows the case to be hopeless. A patient complains of sudden and violent headache, he becomes pale and vomits; if he is able to walk a few steps, the headache, paleness, and vomiting continue; the pulse is soft, consciousness is par tially retained, but the patient is stupefied; by degrees the redness of the face and stupor increase; he answers slowly and with difficulty, and sinks into coma from which he can not be aroused. In these cases there is generally a ruptured blood-vessel from which blood is gradu ally extravasated on the brain. When partial recovery from these severe attacks takes place, there is generally paralysis of one or both sides. In some cases half the tongue, face or larynx remain in this state after consciousness is fully recovered.

7. Effusion into the Cerebellum.-The usual effects are: hemiplegia of the opposite side of the body; sight and hearing are generally affected, from the vicinity of the optic ganglia and auditory nerves; excitement of the generative organs is general, though not universal. In the meningeal form of sanguineous apoplexy there is extravasation of blood on the surface of the brain. We find:

1. Effusion into the cavity of the arachnoid membrane.

2. Effusion into the sub-arachnoid tissue.

In the first variety there is never such a decided rupture of the vessels as is visible to the naked eye, hence it is called an exhalation. But the blood extravasated coagulates in the situation in which it is found, and soon becomes invested by a false membrane which is so fine and delicate, and so closely adapted to the original serous membrane, that the limits of each can scarcely be defined. (Hewitt, Med. Chir. Transac., Vol. X.)

Symptoms. In all cases of this kind there is pain in the head; and it is generally, though not always, followed by paralysis. The most striking characteristic is the occasional intermission of the symptoms. It is generally fatal, though not always so. The intellect remains unchanged so long as the effusion is confined to parts near the base of the brain; when it extends towards the upper part of the hemispheres coma and insensibility ensue. The cephalalgia, redness, heat of the integuments of the face increase as the effusion advances. The intel

lect is weakened by the compression of the brain; but, as there is no inflammation of the hemispherical ganglion, sensibility and the mental faculties remain to be obliterated together when the pain, which be comes more and more excruciating, is overpowered by the extension of the effusion. The distress from the vomiting, the depression, with the feebleness of pulse, the paleness and diminution of sensibility and mental power are proportionate to the danger. (Solly on the Human Brain, p. 379.)

SEROUS APOPLEXY.

Apoplexy, in which the effusion into the brain consists of a serous instead of sanguineous fluid, is usually dependent on general debility, accompanied by local excitement and congestion of an asthenic character. There is paleness and bloatedness of the face, cachectic appearance, vomiting, fits of nausea, and a gradual setting in of complete or partial paralysis.

CAUSES.-It may arise from any of the ordinary causes of debility: as, injudicious depleting treatment of a patient of intemperate habits, in whom a blow on the head had excited subacute inflammation of the brain. In such persons inflammation or strong congestion may be easily excited, but bleeding and active purging only produce depression without lessening disease.

DIAGNOSIS.-Inflammatory apoplexy is for the most part confined to individuals of a sanguine temperament, plethoric, with short, thick necks, vigorous circulation, and a great amount of animal heat. The attack is often preceded by vertigo, unusual heat about the head, face red and full, eyes injected and troubled with muscæ volitantes. The invasion of the malady is so sudden that the patient is struck down instantly, deprived of all consciousness and power of motion. The respiration becomes stertorous, the cheeks and lips puffed out at each. respiration; the pulse is slow and full; the pupils dilated, face red or livid, or purplish, throbbing of the carotid and temporal arteries, eyelids convulsed, either closed or half open; paralysis of the muscles of one side, or of the face only; and distention of the veins of the head and neck. After a time the breathing becomes less stertorous, the pulse more soft, and some signs of returning consciousness indicate convalescence; or, as more often happens, these symptoms become more grave, and the vital forces continue to fail until the patient sinks under the disease.

Some of the marks which characterize serous apoplexy, are: general appearance of debility, face pale and haggard, pulse below the natural standard in frequency and fullness, surface cold and clammy, pupils contracted or dilated, loss of consciousness and paralysis of one or more parts.

VOL IL-41.

If the patient recovers from the more serious symptoms of this malady, there usually remains for a long time a paralytic condition of one or more parts of the body.

A slight injury of the brain may also be so far exasperated as to terminate in serous effusion by injudicious stimulation. Other causes of serous effusion in the brain are: metastasis of various diseases; suppression of secretions; especially, suppression of urine caused by destructive disease of the kidneys. When serous effusion arises from the cause last named, there are symptoms referring to the urinary or gans, as "pain in the bladder, strangury, or inability to retain the urine, which is high-colored and shows its diseased state by its chemical constituents. Severe mental exertion often produces this disease in persons of exhausted constitutions.

SIMPLE APOPLEXY.

The last form of apoplexy to be described, has been called apoplexia simplex, from its leaving no trace of its effects on dissection. It begins and terminates fatally by the pressure of the blood upon the brain, and, also, from the asphyxia caused by the imperfect respiration. The substance of the brain is gradually saturated with undecar bonized blood which contributes to the profound coma in these cases, as well as in many other cases where blood or serum are effused upon the brain. (Solly, 390.)

PROGNOSIS.-In forming an opinion of the event we are guided by the violence of the symptoms, the frequency with which the attacks have occurred, and the constitution of the patient. If the disease is of a sthenic character, if it has been caused by extreme plethora, assisted by some accidental circumstance, as unfavorable posture, slight straining, and there is no evidence of disease of the heart and bloodvessels, the prognosis may be favorable. If the seat of the effusion appears to be at the base of the brain, and not too near the medulla oblongata, it may be remedied. In a large proportion of cases the treatment must be essentially the same "wherever the effusion may exist, or however it may have been produced;" but an accurate diag nosis is still of the utmost importance in directing the extent to which remedial measures may be carried, as well as in calming the minds and retaining the confidence of the friends. The case may be considered more unfavorable when the patient is advanced in age, is of an apopletic habit, and when the powers of the circulation and respiration are paralyzed,-when the breathing is labored, stertorous, slow, superficial and irregular, when the pulse is slow, small and intermitting, deglutition difficult, the alvine and urinary evacuations pass involuntarily, the extremities are cold, a clammy sweat appears on the upper

parts of the body, paralysis increases, and a mechanical grasping at one spot on the side of the head. In some cases there is a partial recovery, leaving a state of mental imbecility. In others, there appears to be an entire recovery; but in all such cases it may be expected to return again on some trifling provocation.

TREATMENT OF APOPLEXY.-1. Of the Premonitory Symptoms.-In all cases where any warning symptoms exist, all possible precautions should be taken to prevent an attack; but all advice should be directed to the friends rather than to the patient himself. Every symptom of disorder of the digestive organs should be attended to; the general health should be promoted in every possible way. All habits of intemperance in eating and drinking should be cautiously but effectually changed; the patient should take much exercise in the open air, with plenty of simple but nutritious food. The amount of stimulants should be lessened, but they should not at first be entirely prohibited.

All mental excitement should be avoided; bronchial affections should be promptly treated; congestion of the lungs which delays the return of blood from the brain to the right side of the heart, must be

immediately removed by proper measures. The act of coughing may excite apopletic effusion. Watson says he has seen fatal apoplexy caused by the straining of a person to pull on his boot; and we have witnessed some cases where it originated in very trifling physical exertion. One of these was a strong man of florid complexion, who drank freely, but was not considered as intemperate. While engaged in boring a hole with an auger in a block of wood on the ground, he fell down in an apoplectic stupor from which he could not be aroused. All exercises that especially exert the lungs, as coughing, blowing on wind instruments, loud talking, singing, as well as venereal excesses, depending posture, severe cold, or the suppression of habitual discharges, may, at any moment, provoke an attack of apoplexy.

For the precursory symptoms of apoplexy, and for its incipient stages, the following remedies are recommended: Aconite, Nux-vomica, Coffea, Belladonna, Ipecac., Arnica, Bryonia, Ignatia, Mercurius. The choice of a remedy in an individual case must be made after an accurate review of the symptoms.

2. Treatment of Sanguineous Apoplexy after the Occurrence of the Attack. All tight clothing should be instantly removed, especially from the neck; carry the patient to a cool place, well supplied with fresh air, and place him in a position in which the head is well elevated. If poison be suspected, remove it by the use of an active emetic, sulphate of zinc, or the stomach pump, and antidote the poison suspected, using strong coffee for opium, (Hartman, Vol. IV., p. 4,) and also for Belladonna.