JAMES TAIT GOODRICH ™~ OMNIFARIAM DoCcTUSH™ PATHOLOGICAL ANATOMY OF THE BRAIN, SPINAL CORD, AND THEIR MEMBRANES. PATHOLOGICAL ANATOMY OF TRE Brain, Spinal Cord, and their {Membranes ; aN j BEING / \ ] A CONDENSED DESCRIPTION OF THE MORBID APPEARANCES GENERALLY MET WITH AFTER DEATH: , WITH CASES. Gm he ON my vy A was w= Illustrated by 13 coloured Plates, NN = BY W. P. COCKS, SURGEON. LONDON: PUBLISHED BY S., HIGHLEY, 174, FLEET STREET, AND WEBB STREET, ST, THOMAS’S HOSPITAL, 1831, PREFACE. THERE are already so many ex- cellent works on Pathology and Morbid Anatomy, that some apo- logy seems due for the obtrusion of the present volume, and if the author could have found a work answering all the purposes it is presumed to answer, he would have bestowed his labours on some other subject. The scope of the Pocket Companion is, however, too limited to justify any vi pretensions to rivalry with the talent- i ed productions which have so honour- ably distinguished the present age, 5 i and its design is to illustrate and ex- | { hibit the most approved opinions on i all subjects that come under notice, | rather than to indulge in novelties, which have not received the sanction of the profession generally, and the test of personal experience ; there are, however, some cases not noticed by others, and many original draw- ings from diseased parts in the author’s possession. vii A comprehensive inquiry into the subject treated of must not be ex- pected in so small'a work as this: the author has desired to keep it within a certain bulk, and his lan- guage will be found, on many occa- sions, more concise than elegant. The motive which led to this un- dertaking, was the great expense of coloured drawings on subjects essen- tially necessary for the student, and it is hoped that these plates, coloured after nature, may be refreshing to the memory even of the more ad- vill vanced inquirer. It frequently hap- pens, that the best written descriptions fall short of that power to identify which the pencil conveys, and with this feeling, the author, in the prose- cution of his pathological researches, has made it his practice, for years past, not only to take written notes of all his post mortem examinations, but sketches also of every change in structure that has appeared at all remarkable or unnsual. In this two- fold character, he solicits the indul- gence of the profession: he is aware that his claims to consideration, as an artist, are too slight to merit any praise, except it be for that fidelity which he has always preferred to elaborate finishing, and in this re- spect, he almost doubts the possibility of finding a non-medical artist, who possesses the power to seize those points ina morbidspecimen, to the nice portraiture of which the sketch owes all its value in the eye of the dis- criminating anatomist. London, 1831 CONTENTS. Arachnoid membrane .... . 1] inflammation. . . . . 38 Morbid Anatomy . . . 39 of the spinal cord . . . 125 Morbid Anatomy . . . 126 RDS a ees a Ge of the spinal cord ossified 135 Brain to prepare for dissection . . . 6 healthy appearance . . . . 14 foetus Bore yy ar ee oe og mee) APs ib. Chaat Sei aes es ORR SO antici A ae ib. method of examining a eat ae WONCRIONONS ics! tiie 60 leek a 8 16 corpus callosum . . . . . ib. PORREE aR We oe ib, corpora stridtaiiges 6 5... AB, Wptie thalaige veges sae ee HO pons Varolil «4 \ isso ian ibs analysis SA! ot 100- Cal ernre 17 xii Brain, fluid on its surface INES 8s a eS inflammation Morbid Anatomy abscesses whee Morbid Anatomy AMR Sern” nial s ulceration . . Morbid Anatomy . Case o @s heey softening Bod baad; Morbid Anatomy abe 5 frsrarduudinns STEEDS esa Dirg induration . . . Morbid Anatomy tumours: «9 3% 3 GS Morbid Anatomy scrofulous Case . flesh-like Case adipose Case scirrhous Case encysted encephaloid fungus melanodes Xi Brain, melanosis . . . . «+ 1 analysis . . + + + « bone etter te ea | DBS ane, oun eine GAVAGIES 6+ 0)” o> eer we BEG, oe UGS as | blood cyst a WENA hy CAKE sin a ee hydatids . 2 wee se 6 Case > = sou wonete ditto os, oes ean oe fluid in the ventricles analysis on an EH By Morbid Anatomy of hydroce- phalus Case a HERD» ti tia gsite apoplexy « . « « meningeal cerebral . Morbid Anatomy .« Case = arteries ossified J ley Case ee Le change of colour hypertrophy Case... s% Cholera morbus Cranium XiV Cranium, method of sawing Se hs dura mater, adhesion to.1 x aramlree: ea te Cases of i insanity. Death from arsenic . - ara sais sulphuric acid . . , sulphurated hydrogen. carbonic acid . . , Prussic acid . . .., by hanging drowning . . , strangulation ott Delirium tremens ADEs Dementia . . , DIRT AMEE Sosy oe, tae inflammation . . , Morbid Anatomy . . Oe et at HERG Fee Se adhesions a softening ... 4, ulceration . . . ., scrofulous tumours adhe- ring to : thickened . . . . , cartilaginous, analysis of fungoid tumours adhering Wu essified ee ae PAGE PAGE Dura mater, ar Sher titi eee 37 eat heh) a kee a s 38 Explanation of the plates Conte Erysipelas . . . . - 47 Form for facilitating the record. of post mortem appearances . . . . . QI Ganglionic nerves Scag aaa.) Patiala hee Gangrene Te ee a te ee 3 PEON og oes | as serait ae RRCOANOS. oc. a) 2. "plus teeouh Side Hydatids, aCe eee ee Insanity sul ene Ue hethiens eas. wa AE Idiotism SS ge pated: stn oe eae 72 DRUM kde 8 Ss eos Monomania ay . tb. Nerves within the cranium. . . . 12] inflammation . ... . . 122 injuries . Wee e Lee heal when w ounded.. a eorae ganglionic alhiteuara: tease geen | ee Pep? distinction between inflam- mation and congestion . 12 inflammation . . . . . 3 Morbid Anatomy . . . 43 veins inflammation . . Morbid Anatomy . . . 48 Case: . Gem. « : airinthe veins . . . , 56 Xvi Pia mater,scrofulous tumours . .°. 57 water on the surface of the VAUD Gesill. iia te Dees ib. eysts adhering to ossified . . Plexus choroides Pineal gland . . Pituitary gland . Pericranium .. . Phthisis pulmonalis Putrefaction . . «6 a Spinal column, fnathiod of opening eanal, an effusion in a CBRE iss, lis oie acu apoplexy Spine fracture . . . . . Spina bifida ... .. Morbid Anatomy Typhus fever . . Wounds before and after death MORBID ANATOMY, Tue following will be found the most convenient method of examining the ex- ternal parts of the head and contents of the cranium. On viewing the head and face, parti- cular attention is to be paid to the in- eguments and the various appearances they present, such as inflammation, spots, cedema, wounds, or sphacelus. Spots.—When the discolouration is the consequence of external violence, a ¢onges- B tion of thick concrete blood will be found; but in the spontaneous spots or suggillation, the blood, on incision, will be seen fluid. Wounds.—Wounds received before death are marked by red bloody and separated edges. Those inflicted afterwards are livid, and their edges close to each other. Simi- lar appearances characterize contusions or blows, in which there has been no solution of continuity; and on dissection they are, if inflicted on the living, found to be sub- cutaneous wounds; vessels are seen torn, and fluids extravasated, and the whole exhibits the marks of tumour in its elasti- city and cireumseribed shape. Violence on the dead body can only produce livid flaccid spots, unattended with infiltration or tumour, Sphacelus.—Gangrene also is surrounded with a red edge: putrefaction is not ; and the spots, caused by the latter, are of various colours. Dry gangrene cannot take place on the dead body, since there is no heat or action of vessels to produce it, but the dis- organization observed is of a humid nature. There are circumstances, however, which invalidate the importance of this sign, and render it somewhat doubtful. Thus, for ex- ample, a man may die of a wound, before in- flammation commences, Others are so de- bilitated, that wounds on them have livid and dry edges, and, after death, can scarcely be distinguished from those inflicted on the dead. Putrefaction comme es gradually when B2 4 the vital principle is extinguished, and after a certain period, which however differs in different bodies, according to the previous diseases, the season of the year, its tempera- ture, &c., it produces an extensive disor- ganization, confounding the cause of death, and rendering it dangerous for any one to examine the body. Taking these facts into consideration, it will be found useful to attend to the following statement of the progress of putrefaction, and the comparative utility of dissection in each : First stage.—A tendency to putrefaction. It consists in a slight alteration of the body, a softness of the flesh, and a disagreeable odour. Dissection is practicable, and still useful 5 Second stage.—Commencing putrefaction. A fetid odour is present, the fleshy parts become light, and assume a dark colour. Dissection is already dangerous, and can be of no use except in particular cases. Third stage.— Advanced putrefaction. The parts exhale an ammoniacal odour, mixed with a putrid smell. They fall into dissolution, and their colour is constantly altering. Dissection is impracticable and useless. Fourth stage.—Complete putrefaction. This is known by the complete dissipation of the ammoniacal odour, and also by the putrid smell losing its strength. The volume and weight of the parts are much diminished, and they separate into a gelatinous mucus, which 6 gradually dries, and at last becomes an earthy and friable mass. To prepare for the dissection of the brain, an incision is to be carried from ear to ear through the scalp. The skin is then dissected off the cra- nium,* and drawn over the face and occi- * Craniwm.—When the bones of the cra- nium are laid bare, search is to be made if there be no fissures or fractures, taking care at the same time not to mistake irregular sutures for them; and for this purpose, they should be rubbed over with ink. Caries and all other diseases of the bones, with the state of the pericranium, are to be carefully noted in the report. The brain is sometimes pressed upon by bony tumours growing from the cranium. A general in- erease of the thickness of the bones of the skull encroaches upon the brain, and sub- «J put. In cutting through the skull some nicety is required. On the anterior part the cut should not be made lower than half an inch above the frontal sinuses, but it may be carried to a lower level be- hind. Before the saw is applied, a piece of whip-cord may be tied firmly round the skull as a mark for the circular inci- sion. The saw should not be carried through all the tables of the skull; but after having cut through the external jects it to all the effects of continued pres- sure. A nodule of ossific matter, resembling ivory in hardness and appearance, has been found growing from the cranium. Bony ridges and spieuls of bone occasionally grow from the cranium and its proces: 8 and middle tables, we should endeavour to break the vitreous table with the chisel and mallet. In some cases, the dura mater adheres so firmly to the parietal bones, that it is impossible to raise the scull-cap without using great force, or the scalpel. After the roof of the skull is removed, the chin must be supported on a tripod or block. The dura mater should be minutely examined, in order to ascertain whether there is any fungous production upon it, or depression in the corresponding part of the bony arch. When adhesion exists, and when the sinuses are gorged with blood, the fact should be stated in the 9 report. When pus or blood is effused between the membrane and bone we should ascertain its source. The dura mater should be washed, to enable us to determine whether any change of colour has taken place, and if the discolouration be owing to a fluid effused on its surface, or produced by in- flammation. The scissors may now be run along the longitudinal sinus, and the ‘manner of the opening of the veins into it noticed, and the glandule Pac- chioni, carefully examined. (I imagine that an enlarged state of these glands is frequently the cause of diseases of the head, preventing, as it does, the free 10 egress of the blood from the veins of the cere brum into the longitudinal sinus.) The dura mater is now to be divided by a horizontal incision carried opposite to the ear on both sides, continuing the division forwards nearly to the perpen- dicular ridge of the occipital bone... The lateral parts of the dura mater may then be turned up towards the longitudinal sinus ; this will expose the surface of the brain, the falx cerebri, and the fissure between the hemispheres. The falx must be cut from the crista galli, raised out of the fissure between the hemispheres, and the dura mater turned backwards. 1] We now see the whole of the upper surface ofthe cerebrum. The removal of the dura mater should be done gently, and it will then be seen whether any adhesions exist between it and the arachnoid mem- brane. If there be no effusion of serum on the surface of the brain, it will be difficult to see the arachnoid membrane, on ac- count of its transparency; but when there is effusion, it is apparent without any difficulty, as it is a little thick- ened. After minutely examining the arachnoid membrane, inspect the convo- lutions of the hemispheres: if they are flattened in any considerable degree, it 12 indicates an effusion of fluid into the lateral ventricles. It is difficult to trace the arachnoid membrane to all the parts of the brain to which it is said togo. It may, how- ever, be easily traced over the surface passing from one convolution to another without descending between them. The ventricles are lined with this membrane, which is thickest at the base of the brain. The next membrane is the delicate, but vascular pia mater,* loaded with arteries * Pia Mater.—The bright red, and espe- cially when the redness is diffused in the inter- stices of the vessels, denotes inflammation; while the retarded circulation produces only turgidity of the vessels. and veins; and when we pull a por- tion of it, we find it passing down into the substance of the brain, and be- tween the conyolutions. We also find it prolonged into the ventricles, assuming the name of the plexus choroides. Its inner surface is in close contact with the cerebral substance; its external with the arachnoid membrane on. the surface of the convolutions, but loses all connexion with it after passing into the sulci. At its entrance into the ventricle, the plexus is drawn together, so as to resemble a small vascular bundle, and becomes in- vested by the arachnoid membrane, which, by its reflection from the sides 14 of the ventricles to the plexus, maintains the integrity of the cavity. *The hemispheres being uncovered * Hemispheres.—The brain when ina very recent state is of a purplish brown colour, and somewhat elastic ; it is firm to the touch, and may be divided into thin slices without any part of it adhering to the knife, and may be stretched to a certain degree without tearing. But when it has been exposed to the air for an hour or an hour and a half, or when examined after the lapse of twenty- four or thirty hours after death, even al- though death has not been occasioned by disorders which affect the nervous system, the brain is soft, readily torn, and a portion of it adheres to the knife, unless the knife has been previously dipped in oil or water, and it falls to pieces on being slightly stretched. A slice of recent brain, put into water, does not render the water turbid for ten or twelve hours, : 15 may be drawn aside, so as to expose the corpus callosum, and its substance may be cut through* by passing down Brain of the fetus and of the child just born, appears to consist almost entirely of a cineritious pulp, to such a degree, that the medullary substance is difficult to perceive init. During infancy the brain is redder and much softer than during the meridian of life; and it gradually becomes harder upon the approach of old age. * Cut through.—The best way is to slice the brain off by several horizontal incisions, and let any change, either of colour or consist- ence, be carefully examined. The appearance of the grey substance should be noted; it may be of a slightly rosy tinge, or may present a sort of dotted redness, particularly when the pia mater is much injected; in other cases the texture of the convolutions is altered, being rendered soft or almost diflluent by inflammation and 16 a scalpel to a level with the corpus callosum, and then directing its edge outwards and upwards, so as to avoid entering the ventricle.* The ventricle suppuration. It is generally stated, that the superficial cineritious substance of the brain presides over intellectual functions, and its white and deep-seated gy mass over locomotion. * The Ventricles—We should never fail to examine very carefully the state of the serous membrane which lines them, and the colour and quantity of fluid found in them. The state of the corpus callosum, fornix, orpora striata, optic thalami, and pons varolii should be fully stated, taking care with regard to this last to indicate the side of it which is particularly affected. The white substance in the deeper parts of the brain, as that around the ventricles and corpus striatum, is in the healthy state softer than that towards the surface. 7 may be opened by making an_inci- sion through the corpus callosum, pa- M. Magendie states, that there exists round the brain and spinal marrow a liquid mass, varying in density according to the parts in which it is found, and occupying the space between the surface of these organs and their membranous coverings. He says, ** T have proved, by a sufficient number of examinations, that this fluid constantly exists in man; that it is a sign of the healthy and not diseased state, as some medical men, who seeing it only or by chance have been led to believe. The quantity of this fluid, which I call cephalo-spinal, is never less in the adult than two ounces, and sometimes amounts to five in tall persons, and those whose skulls are large. Analysis of the brain, of the cerebellum, and spinal marrow: SSR AS Resocinec «-» 80.00 White fatty matter ..-.se000. 453 18 rallel with the raphe, and everting the external portion of it. The parts within the body and interior and posterior horn of the ventricle being examined, the de- scending horn may be traced by fol- lowing the plexus choroides downwards into it, after which it can be fully ex- posed by making an incision through the substance of the optic thalamus down to the cornu, Red fatty matter Osmazome Albumen Phosphorus Sulphur and salts, such as— Phosphate of Potass ————— Lime 19 If the cornua ammonis be drawn out- wards, the point at which the plexus enters will distinctly appear; and also the change presented by the pia mater where it enters the ventricle. The greater part of the substance of the hemisphere may now be removed, and the tentorium cerebelli at the same time detached from the pars petrosa, and reflected backwards. This will expose the greater number of the cerebral nerves, with their course and relations within the cranium. METHOD OF OPENING THE VERTEBRAL COLUMN. The easiest way to open the spinal canal is to cut through the roots of the spinous processes with a saw, or, what is still better, with a large knife (a plumber’s hacking knife) and a mallet, and then tear up the processes with a pair of pincers. This will expose the sheath of the spinal marrow, which is a continuation of the dura mater. The membranes and substanc®@ of the spinal marrow should then be examined, with those precau- tions which have been recommended in examining the brain. 2] A form for facilitating the record of post mortem appearances, in the order in which they present themselves. The blank spaces are to be filled up with the appearances of the parts facing which they stand, Post Mortem examination of Age Disease Date By whom performed. External appearance of the head, face, eyes, and ears ....... POTICHAAHUTO ooo s-. 5 wine sc ocala Bones of the head .......... STR NGUGT ce: ach troche Longitudinal sinuses ........ Pia mater ... Convolutions and substance of the cerebrum Ventricles Corpora striata Thalami nervorum opticorum Pineal gland MGFATUGG. is bes Se oe oe Commissures Infundibulum and _ pituitary 5 3 Corpus pyramidale .......... Corpus restiformes ......... Medulla oblongata ...... ee - spinalis ......... ort ENGENCH o orsig ors we kind vie oe wrens Arteries ...... :,, _. S Substance of the cerebellum .. DISEASE OF THE PERICRANIUM, (PERIOSTITIS.) Symptoms. — Head-ach, with various uneasy feelings about the head; painful tenderness of the scalp in some particular part, with some degree of swelling or thickening of the integuments there. 24. MORBID ANATOMY. The pericranium is generally found thickened, and firmly attached to the bones of thehead. In some cases it pre- sents quite a cartilaginous texture, nearly three-quarters of an inch in thickness. When removed from the skull, the bone or bones are found to be very much de- stroyed by absorption, particularly the outer table and its texture resembles that of coarse spunge, but very white. In such cases, you generally find some or- ganic derangement within the cranium. Case.—A boy, aged fourteen years, had a small angry tumour on one side of the nose, 25 which extended to the forehead, with erysi- pelas and fever. He suddenly became eom- atose, then convulsed, and soon died. Dissection. —The pericranium of the frontal bone was found red, thickened, and detached from the bone, there being much purulent matter lying between them. The dura mater was detached from a correspond- ing space of bone internally, and a greenish fluid was effused between them. The following are some of the recog- nized alterations of structure of the brain and its membranes. CONCUSSION OF THE BRAIN. Symptoms,—Slight cases of concus- sion are marked by giddiness, dimness 26 of sight, weakness of the limbs, trem- bling, and nausea. In severe cases the person becomes insensible, face pale, skin cold, with relaxation of the limbs, low and weak breathing, feeble pulse, and the pupils fixed and insensible, stertorous breathing—death. When the effects of concussion subside the sensibility gra- dually returns, the pupils contract, the pulse rises, the skin becomes warmer, the patient can be roused from the co- — matose state as from a sleep; or sensi- bility returns at intervals, he awakes, answers questions, and again relapses; on reviving, there is confusion of intellect or delirium. 27 MORBID ANATOMY. With respect to the state of the brain under concussion, when the injury has not been excessively severe, it seems that the symptoms are merely the effects of a disturbance of the natural course of the blood through the brain. It seldom happens that this state of the brain de- stroys; but when it does so, nothing is found upon examination which will ac- count for the symptoms. It is, there- fore, an alteration of function, but not a disorganization, When concussion is very violent, it is attended with lesion of the brain, which is generally attended with slight extravasation. 28 When fracture * of the skull has immediately preceded the patient’s death, there will be coagulated blood found upon the bone and in the fissures; if the’ patient has survived for some time, there will be marks of inflammation, and per- haps pus, in contact with the skull; but * Fractwre.—A fracture may be as distinct- ly observed, and is as good a proof two months after death as one day; and this, notwithstanding the putrefaction that may be present. In severe cases of concussion or fractures of the skull, where compression of the brain is apparent, the extravasated blood is gene- rally met with in three different situations :— first, between the dura mater and pia mater ; secondly, between the pia mater and brain; thirdly, within the substance of the brain. 99 if fracture has been produced in making the examination, the blood in the fracture will not be coagulated, nor will there be ‘any effusion around the portions of bone. When there has been a blow received, though there be no fissures externally dis- cernible on the skull, yet we examine whether there is a breaking in of the tabula vitrea. Although no fracture may exist, there is often an extravasation of blood under the cranium; owing to the shock and consequent separation of the dura mater, 80 INFLAMMATION OF THE DURA MATER. Inflammation of this membrane arises from injuries done to the skull, and the symptoms are—nausea, vomiting, thirst, head-ach, vertigo, confusion of sight, quick, full, and hard pulse, restlessness, pain and tense feel of the head. The symptoms indicating suppuration within the cranium, never appear at an earlier period than the sixth day; generally be- tween the eighth and twenticth days. MORBID ANATOMY. There is generally found a small quan- tity of purulent matter lying (at the site of the injury) on the surface of the dura 3] mater. When this membrane is raised, it presents a degree of redness more or less intense, and its vessels are sur- charged with crimson-coloured blood. At the same time we find the entire sur- face of the hemisphere covered by a yel- low purulent fluid, which adheres so te- naciously to the pia mater that very little of it will flow off; indeed, the colour and consistence of this fluid would lead us to suppose, that it was formed of a commixture of pus and coagulated lymph. Sometimes matter has been formed within the cranium so early as the third and fourth days. 32 A CASE OF IDIOPATHIC INFLAMMATION OF THE DURA MATER. The symptoms were irregular attacks of fever, want of sleep, loss of appetite, nausea, and severe headach, delirum, coma—death. DISSECTION. On raising the calvarium, a good deal of purulent matter escaped, which had been collected betwixt the bone and the dura mater. The space, in which it had been contained, was defined by an irregular ele- vated margin of adventitious membrane, by which the dura mater had adhered to the bone, the included space being about? the size of a crown piece; it was on the anterior part of the right hemisphere. The dura 33 mater included within this space was de- pressed, its surface was in some places ulcer- ated, and in others black; but the mem- brane was quite entire, and the bone was sound. On raising the dura mater, the inner surface of this portion had the same irregular ulcerated appearance as the outer surface, and when held up to the light, the mem- brane at the part appeared to be in some places considerably thickened, in others very thin. When the dura mater is inflamed, ad- hesions are frequently formed between it and the other membranes. In softening of the dura mater its la- mine are separated, and present at cer- D 34 tain points a flocculent appearance, as if it had undergone maceration for some time in a weak solution of acetic acid. There are seldom or never any vessels to be seen in the neighbourhood of the softened parts. Ulceration of this membrane is of very rare occurrence. Scrofulous tumours are found adhering and sometimes passing through the tex- ture of the dura mater. They are generally indurated and regular in their formation. They receive a covering from the arachnoid. They present, when sliced, a smooth omogenous substance of a pale straw 35 colour, similar in appearance to the ker- nel of a horse-chesnut. Sometimes the centre of these tumours undergoes the softening process, and presents a curdly matter. The dura mater is frequently found thickened and more opaque than natural. At some points the deposition of carti- laginous matter* is very great, and pre- So * Cartilaginous matter.—Cartilage, when divided, seems to be homogenous, and with- out any appearance of fibres, vessels, or nerves; but, when carefully macerated in a weak solution of acetic acid for a few months, a fibrous texture becomes apparent, and the phenomena, which they exhibit in health and disease, prove the existence of a vascular and nervous structure, 36 sents a nodosity of some thickness. I have met with tumours of this kind which equalled in size a large orange. Fungoid tumours are fibrous in their texture, sometimes crossed by enlarged blood-vessels. In some points they be- come softened and broken down, and contain blood effused into their substance. In some cases we find only one of them, in others several; which may be en- cysted, circumscribed, and more or less irregular. At first they are flattened before the escape beyond the skull, and afterwards assume the form of a mush- room, the pedicle corresponding to the aperture in the cranium. 37 A deposition of bony matter* into the texture of the dura mater, and between it and the arachnoid membrane, is fre- quently met with. The patches are small, irregular, and scaly; the falx cerebri and tentorium have been found com- pletely ossified. * Chemical Analysis of the Bone. Cartilage téo:s0 ses seace CRE Soe 32.17 PUGUR- COREE S =) sole cia ders onaeieen 113 Fluste‘of lime: “ios202 oc noce eens 2 Phosphate ..... Ces Celweanceddee 51.09 Carbonate of lime...... seveseeses 11.30 Phosphate of magnesia .......... 1.16 Soda, muriate of soda and water .. 1.20 38 Bony maiter.—A CasE.—On opening the head, and slitting up the dura mater, there was found on the inner surface of the part of that membrane corresponding to the middle of the left temple, a solid mass of bone, up- wards of an inch in length, and about half an inch in breadth, with very irregular sharp edges, and as thick as a crown piece. Two small pieces of bone, each the size of a barley-eorn, were also found attached to the duramater, and situated at small distances from the larger ossification. INFLAMMATION OF THE ARACHNOID MEM-~ BRANE AND PIA MATER. Ir is very difficult to distinguish in- flammation of the arachnoid membrane 39 from that of the pia mater. The symp- toms are—head-ach, nausea, vomiting, fever, impatience of light, want of sleep, delirium. The attack is most commonly preceded by sudden and long-continued paroxysms of convulsion, and, in some cases, by head-ach and vomiting. MORBID ANATOMY. When meningitis has existed for some time, the arachnoid membrane acquires a real increase, both of thickness and density; it loses its transparency, and presents somewhat of a milky appear- ance. It has sometimes acquired the 40 thickness of the pleura, pericardium, and even of the dura mater. The arachnoid is sometimes covered with a false membrane, more or less thick, and more or less extensive; but it is rare to find adhesions between the two layers of the membrane. This membrane may lose its polished appearance, become rough, and covered with small granulations, which, when very minute, give it an appearance as if covered with down. This is generally observed in the ventricles. Cartilaginous depositions and chalk- like spots have been found in that part of the arachnoid membrane which covers 4] the spinal marrow. Bone has been found in the same situation, but this last is a rare occurrence. Delirium tremens seems to differ from all other mental derangements. It comes on gradually, and several days elapse before it arrives at the stage of its greatest violence, It is attended by tremors of the whole body, but particularly of the hands, with profuse sweating, and almost insuperable watchful- ness, In delirium tremens the veins of the pia mater are very much loaded, and generally there is an effusion of serum between the pia mater and arachnoid membrane. Typhus Fever.—The pia mater is consider- ably surcharged with a dark fluid blood, the | ie ie hy 42 arachnoid is milky or opaque in some places, and a serous fluid, and sometimes spots of lymph, are effused between the two mem- branes, while the substance of the brain itself, when sliced, exhibits more bloody points than natural, The appearance of the brain generally met with in those who die of cholera in the East Indies—the sinuses and veins of the brain and its membranes are always dis- tended with black, thick, and viscid blood; the tunica arachnoidea is frequently opaque and somewhat thickened, and adherent to the adjoining membranes. The brain is sometimes soft and pulpy ; but it seldom pre- sents any very decided marks of increased action. 43 PIA MATER. In inflammation of the pia mater, the vessels are much more numerous than in its natural state; they are filled with a flo- rid blood, and form, by their anastomosis, a beautiful net-work. It does not fre- quently occur, when the pia mater is in- flamed, that it becomes so uniformly red as to shew no interstices between its vessels—a circumstance which happens in the inflammation of some other mem- branes. When the pia mater is inflamed in a high degree, pus is generally formed, and sometimes diffused over the whole upper surface of the brain. Dura mater,—Cast.—A young gentleman 44 had experienced for twelve or fifteen days an intense head-ach, principally at the bot- toms of the orbits, and then was seized with delirium, fever, agitation, and occasional vomitings, Dissection.—The internal surface of the dura mater was found in some places covered with a layer of nearly fluid pus; the mem- brane itself was highly injected. A great portion of the superior surface of the hemi- spheres presented the appearance of pus, being soft, yellow, and nearly liquid. The same was seen in the fissura magna, and several other parts of the brain’s superficies. The pia mater was every where intensely in- jected. Case of Hydrophobia.—Upon dissecting 45 back the scalp, it did not exhibit any undue degree of vascularity. The inner sur- face of the calvaria was turgid with blood, The dura mater presented a general scar- let blush ; and upon raising it from the sur- face of the tunica arachnoidea, a preter- natural adhesion was observed parallel to the course of the longitudinal sinus upon the left hemisphere of the cerebrum, The tunica arachnoidea was observed to be opaque in patches; but this appearance was not gene- ral. There was not any effusion beneath it, between it and the pia mater. The pia mater manifested a great degree of vascula- rity; a general vivid redness pervaded its whole surface. The vessels upon the sur- face of the cerebrum were gorged with blood, 46 Several horizontal sections of the substance of the cerebrum, displaying its medullary ——+ ene aee structure, exposed numerous bloody points, vee a from which blood afterwards oozed; in fact, the substance of the cerebrum appeared in- jected with blood. Nothing remarkable was observed in the lateral ventricles, nor was there any deviation from the usual appear- ance in the plexus choroides of each side, or the velum interpositum connecting them. In the commissura mollis no deviation from its usual consistency was noticed. The pia mater investing the cerebellum was particularly vascular ; but the substance of the cerebellum did not partake of the vascularity ; its consistence was softer than usual. The medulla oblongata was natural; the theca yertebralis very vascular. 47 The bones of the skull were remarkably thin, Erysipelas——The brain always exhibits traces of excessive vascular action. Its ves- sels are over distended with blood ; lymph and serum are deposited upon and between the arachnoid coat and dura mater, and at the basis of the brain; and sometimes the lateral ventricles are filled with serum. CONGESTION OF BLOOD IN THE YEINS OF THE PIA MATER. Symptoms.—Giddiness, confusion of in- tellect, heaviness approaching to sleepi- nesg, and sometimes complete stupor. MORBID ANATOMY. The most common morbid appearance of the pia mater is that of the veins being surcharged with blood. The larger vessels are distended to their utmost ex- tent, and the capillary vessels are empty. Congestion.—Congestion of blood in the veins of the head isa very common appear- ance after death, particularly so in persons who have been subject to chronic disease. Death from Arsenic.—The brain has sel- dom been examined. It is generally natural ; but, in one case, it is stated to have been unusually turgid on its external surface, and the plexus choroides very vascular. Death from Sulphuric Acid.—The patient survived two months after taking the acid. 49 INFLAMMATION OF THE VEINS. Symptoms. — Severe head-ach, fever, nausea, convulsions, rigors, delirium, coma, death. Head. — Clear lymph beneath the dura mater, diffused over the whole brain. The Same coagulated beneath the tunica arach- noidea, and all the cerebral vessels much gorged. Small quantity of fluid in the late- ral ventricles. Basis of brain natural. Death from Carbonic Acid —The vessels of the head and brain are filled with a dark fluid blood, which flows freely from the slightest incision. Effusion of serum, tinged with blood, is found, particularly in the ventricles, Death from Sulphurated Hydrogen. The head was putrid within forty hours after death ; the skin bluish and elevated by gas, E 50 MORBID ANATOMY. When the internal tunic of a vein pre- sents any traces of inflammation, the The blood inthe sinuses of the brain was black and fluid. The substance of the brain softened, and of a greenish hue, a ea Death by Hanging.—The principal vessels of the neck and head are generally filled with blood, and those of the brain sometimes rup- tured. Death by Drowning—A great accumula- tion of blood in the cerebral vessels and jugu- lar vein. Death by Strangulation.—In the case of a woman who had been strangled per manum, the tympanum of the left ear was lacerated, and from it flowed about an ounce’of blood ; the vessels of the brain were unusually tur- gid; red blood was extravasated in the ven- tricles, and also on the base of the cranium. 51 cellular texture, which is situated at the exterior of the tunic, is observed to be much injected, and that injection is li- mited to the inflamed part; but if the inflammation be more advanced, the in- ternal tunic is reddened all over, and there are no interspaces of white appear- Death from Prussic Acid.—The pia mater and vessels of the brain are generally found surcharged with blood, and it emits the smell of bitter almonds, Subacute meningeal Inflammation in the Phthisical, during the last Days or Weeks of Ewistence—The pia mater and the cho- roid plexus are more or less injected ; the arachnoid is dull, opaque, and lustreless ; the sub-arachnoid tissue is infiltrated, espe- cially in the vicinity of the vessels ; and se- rum is effused in the ventricles, E 2 59 os ance; in proportion to the degree of in- flammation, is the colour more intense. This colour is very different from that which is produced by the mere absorption of the blood; for it may be easily seen, that the colour in cases of inflammation depends upon the quantity of blood con- tained in the small vessels, which are spread out on the internal surface of the vein. These vessels have a reticular dis- position; and it is in this sort of net- work that the inflammation is principally seated. Afterwards the other tunics be- come implicated, and the coats of the yein then look like a homogenous mass. In these cases the internal tunic is more 53 or less thickened ; the sides of the vein become sometimes so much enlarged, that, on making a transverse section of it, the cavity remains of a circular figure like the section of an artery. The veins hav- ing been, or being, thus affected, present some varieties of appearance ; sometimes their sides are smooth, and shining; at other times uneven ; sometimes in a state of suppuration, with small ulcerated sur- faces; and when such veins float in water their surface has a villous appearance. It sometimes happens, that, in conse- quence of inflammation, an exudation of albuminous matter takes place, as in croup, which lines the internal tunic 54 completely, or partially, varying also in its consistency, in proportion to the de- gree of inflammation. Sometimes the sepa- ration of it from the sides of the vein is easily effected, and at other times it ad- heres with great tenacity, so that it is impossible completely to detach it. Case.—Inflammation of the Veins of the Brain.—After removing the calvarium, a longitudinal incision of the dura mater on the right side of the falx, shewed that the middle vein of the cerebrum was very much swollen and tortuous, especially on approaching the falx, where it was about to open into the supe- rior longitudinal sinus ; it was of the size of a common pen. It was found filled with a vo yellow puriform matter which obliterated its eavity. In the course of this vein, the arach- noid was of a transparent white colour. The corresponding vein on the opposite side was in the same state. In detaching the falx, a tumour was remarked along its surface, from two to three inches in length, and from ten to twelve lines in thickness, This tumour, on which could be distinguished the tissue of the arachnoid and dura mater in the healthy state, occupied the course and situ- ation of the superior longitudinal sinus. On dissection, it appeared to be formed of a grey- ish cellular tissue, and was filled with pus. The whole cavity of the sinus was thus de- generated, , The lateral ventricles were empty. On a a ae 56 making a longitudinal section of the left hemisphere, considerable disorganization was discovered in all the posterior, and in a great part of the middle lobe, on the outer side of the lateral ventricle. This was formed by the entrance of yellow pus into the cere- bral substance, There was also an effusion of serum at the base of the cranium. AIR IN THE VEINS OF THE PIA MATER Is of very unusual occurrence, although the contrary has been stated by some pathological writers. Two cases out of several hundreds of patients who died of malignant fever, and who were examined twenty hours after death, did exhibit bubbles of air in the larger veins ; and 57 the blood in the heart apparently con- tained a quantity of gas mixed up with it, and it was in a fluid state, and of a rich purple colour. SCROFULOUS TUMOURS Are sometimes met with adhering firm- lyto the cerebral surface of the pia mater. In texture, they are similar to the glands when afflicted with scrofula. WATER ON THE SURFACE OF THE BRAIN BETWEEN THE MEMBRANES. Water is sometimes poured out be- tween the pia mater and brain. There is in these cases generally a greater quan- tity than natural in the lateral ventricles. 58 A more common situation for fluid, than the last, is between the pia mater and arachnoid membrane, either in sepa- rate portions, or effused over a large ex- tent. In such cases, the vessels of the pia mater are more than ordinarily dis- tended with blood. The arachnoid membrane is genenally thickened and opaque. When effusion in this situation is considerable, there is frequently fluid in the theca vertebralis. cysTs. Small cysts have been found attached to the posterior cerebral surface of the brain. They contain a small quantity of 59 a limped fluid, and in the generality of cases are produced by a separation and an elongation of the arachnoid membrane from the pia mater. A PART OF THE PIA MATER BONY. Case.—An individual, forty-nine years of age, who died from softening of the brain. A portion of the pia mater was converted into bone. The ossified part consisted of two flat pieces, about the size of an inch, which adhered to the brain by one of their sides, and the other to the arachnoid. INFLAMMATION OF THE SURSTANCE OF THE BRAIN. Symptoms.—Sense of weight in the head, tinglings in the ears, deception of Se 60 vision, irritability of the retina, numb- ness of one side of the body, pain or prickling of the limbs, convulsions, pa- ralysis, coma. MORBID ANATOMY. The medullary matter is in most cases altered, though not in a very striking degree. It loses something of the usual pearly whiteness which it exhibits in healthy adults, and acquires a faint tint of red, somewhat approaching the colour of peach blossom, or the tinge of redness which belongs to it in the infantile state, The cineritious portion also becoming redder at the same time, there is an ap- 61 proach to each other in the colour of the two substances, which greatly les- sens the distinction between them. The venous trunks, which traverse the medul- lary substance, and which are hardly seen in health, become numerous and conspicuous, and acquire unusual firm- ness, so as to admit of being drawn out with the forceps to the extent of perhaps half an inch; at the same time, numerous minute drops of blood are seen to issue, when the substance is divided, so as to give it a speckled appearance, or as if sprinkled over with brick-dust. There is also an increase of firmness in the ge- neral substance of the organ, produced 62 by recent inflammation, and which tends to preserve it longer than usual from decay. ABSCESSES. Symptoms. — Of suppuration of the brain, violent and constant pain in the head, disturbed sleep, rigors, convulsions of the extremities, involuntary piercing cries, dejected countenance, accompanied with a lemon tint of skin, MORBID ANATOMY. The red colour of the cerebral matter gradually disappears, the blood is re- placed by a sero-purulent fluid which 63 enters into the substance of the brain, combines with it, and gives to it, accord- ing to the extent of the admixture, a greyish dull white, or yellowish green colour. Sometimes pus is formed in distinct abscesses lined by a soft cyst, or an ex- tensive portion of the cerebral substance is found in a broken-down corrupted state, in which, without any well-defined cavity, pus is found mixed with the dis- organized cerebral matter. When ab- scesses are small, there is an ulcerated appearance of the cavity in which the pus is contained. 64 ABSCESS OF THE CEREBELLUM. CasE.—The surface of the brain was na- tural, the substance shewed marks of in- creased vascularity, and the ventricles were distended with colourless fluid. The left lobe of the cerebellum was entirely converted into a bag of purulent matter of a greenish colour and intolerable fetor. The sac was soft and organized, and appeared to be of recent formation. Symptoms were—pain in the left ear, violent head-ach, dilatation of the pupils, squinting, coma, death, ULCERATION OF THE BRAIN. Examples of ulceration of the brain are very rare, and when they have been found, they have generally been seated 65 in the interior of the ventricles, the results of chronic irritation, The symptoms are, violent head-ach, with a sense of tightness, nausea, vomiting, great pros- tration of strength, giddiness, convulsive motions of the limbs, paralysis. MORBID ANATOMY. Ulceration or solution of part of either of the surfaces or middle portion of the brain, so as to present a hollow or de- pressed surface, rough, irregular, and covered partially with bloody or albumi- nous exudations, Case.— Ulceration of the Brain.—It pre- sented.on the lower part of the right anterior F 66 lobe anulcer, measuring seven lines by three, of a yellowish appearance, having its surface hard and dry, and its edges unequal and rag- ged; the cerebral substance lying beneath it was healthy ; the portions of dura and pia mater, which covered that part of the brain, were destroyed by erosin. The rest of the organ presented no alteration. The pia mater was acutely inflamed, and the sinuses were gorged with blood. SOFTENING OF THE BRAIN. Symptoms. — Dull pain or sense of weight in the head, impaired memory, somnolence, deafness, loss of vision, and the power of utterance, paralytic affec- tionsof the face, head, and members, coma, MORBID ANATOMY. Softness in a greater or less degree of the cerebral matter, but without any change of the natural colour. This is, however, different from the suppurative process, having neither the colour nor the foetor of pus; but the medullary portion of the brain in which it is most commonly observed, retains its pure milky whiteness and homogeneous quality, whilst the grey substance re- mains in its natural state, whatever be the degree of softening. It may be found in any part of the brain, but most commonly in the dense 68 white matter forming the corpus callo- sum, fornix, and septum lucidum. The septum is generally found in such cases perforated by a ragged irregular opening, and the fornix has either entirely lost both its figure and its consistence, or re- tains its figure while it is left untouched, but falls down into a soft mass when the slightest attempt is made to raise it. It has been stated that no vessels can be traced into the diseased portions of brain altered by softening; and several writers consider this degeneration to be disease of the nervous system, altogether independent of inflammation, It is true that this morbid alteration 69 has been observed in cases in which no trace of local congestion could be found ; but, in general, the membranes in the neighbourhood are found red and thick- ened, and their vessels injected with blood, and sometimes those which penetrate into the substance of the medulla, though not visible in the healthy state, become so by being injected, and give to the part a more or less deep tinge of red. These circumstances tend to shew that soften- ing is produced by inflammation, which is further confirmed by the fact, that it is constantly seated in those parts of the brain which are most vascular in their structure, such as the corpora striata; 70 optic thalami, and convolutions of the brain. Case. — The patient just prior to death was the subject of hemiplegia of the right side; sensation and power of motion were nearly gone, particularly of the right leg. On examination after death no lesion could be discovered, excepting in the left corpus striatum, which was red and very soft ; and in the thalamus opticus of the same side, Which had undergone a similar change. Case.—In a patient who died of disease of the brain and had hemiplegia, the optic tha- lamus and corpus striatum of the side oppo- site to that on which the paralysis existed were found completely softened. INDURATION OF THE BRAIN. Symptoms.—This state of brain occa- sions loss of memory and derangement of re the mental faculties, and its long endu- rance is calculated to induce that com- plete obliteration of the intellect which constitutes fatuity.* * Insanity, in its ordinary acceptation, is usually divided into mania, melancholia, and idiocy. The following is the order pursued by Esquirol, which is certainly better caleu- lated to illustrate the varied appearances of the disease :— 1. Mania—in which the hallucination ex- tends to all kinds of objects, and is accompa- nied with some excitements. 2. Monomania, or melancholy—in which the hallucination is confined to a single ob- ject, or to a small number ef objects. 3. Dementia—wherein the person is ren- dered incapable of reasoning, in consequence PETRIE se ae 4 i MORBID ANATOMY. Instead of the usual compressible elas- tic character which it presents in the Sound state, the brain may become like coagulated or boiled albumen, or like a portion of brain which has been im- mersed in strong alcohol or dilute acid. It will bear to be pulled out with some force, and will readily re-act so as to restore itself; or when pressed, will re- cover its former shape. The medullary matter is almost invariably penetrated of functional discrder of the brain not con- genital, 4. Idiotism — congenital, from original maleonformation in the organ of thought. - 73 with numerous loaded capillaries, and more or less effusion of serous fluid is found beneath the arachnoid membrane and in the ventricles. The latter are sometimes much dilated. In an extreme state of atrophy and hard- ening found in the brains of idiots, the induration differs from that already de- scribed, chiefly in degree. A portion of brain, so changed, becomes a compact in- organic-looking mass, resembling in co- lour, consistency, and density, indurated egg oreven cheese. Thecerebralsubstance is depressed, shrunk, and condensed, and seems utterly void of vessels or capilla- ries. This hardening affects the white matter more than the grey. 74 TUMOURS IN THE SUBSTANCE AND ON THE SURFACE OF THE BRAIN. Symptoms.—Severe head-achs, conti- nued or intermittent, with twitching of one or more of the extremities, pallid 6a: oe eee fiesb-like . . 9s (1s peo 78 ACIPORe. | s - Miss as See 80 scirrhous + «+ » + * * 81 enewsted. i »¢ -= ube ees 83 Hihy .. <.20)> »- 4 cece ee fibro-cartilaginous . + > . 160 Vitreous table of the skuly . . + > 8 Wintricles ©. y-58 os ae a so re 16 parts within - + + + + 18 containing blood’ . « + + 107 containing a serous fluid 101 Vertebral column, method of opening 20 Veins, inflammation : oe distinction between absorption andinflammation. +. + * coats thickened « + + -* PAGE Veins, suppuration of . . . . . 53 UICGRASION GE soy aE ek Coe eee exudation of albumen . . . ib. RAG Sheers arg ane! ale cied ae, Le containing air ee eta ae Velum interpositum . . . . . . 160 fungus arising from it ib. Ulceration of the dura mater . . . 34 veins Se any ee cron DG MRED DY as oetscel 64 Wounds before death . . . . . . Q Lr ee eee ie dente ss a ib. death before inflammation eommenibes, si sce aie eae MARJETTE AND SAVILL, PRINTERS, ST. MARTL 4 So