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CLINICAL REMARKS, BY DR. BRINTON, AT THE ROYAL FREE HOSPITAL.
irritation of the bladder. The fever of the first sitting are often
rigors and subsequent evident effect of our doing too much at a time; while the subsequent attacks are often as clearly kept up and increased whenever our operative proceedings are of a nature to irritate the bladder, or when the detritus is abundant and not readily discharged. I consider the fever to be irritative, and not inflammatory, for it sometimes appears immediately after the first operation; and although the first attacks may be severe, they often disappear in two or three days under palliative treatment. Again, in some patients of a nervous and irritable temperament, each sitting, however short, gives rise to an attack of fever, often preceded by rigors, but the febrile symptoms disappear in a few hours. Lastly, a febrile attack of the same kind as that now described, which may be severe, and continue for several days, is sometimes excited, in spite of every caution, by simple examination with the sound or catheter. The practical conclusion to be drawn from the nature and causes of this fever is, that, to prevent it, we should avoid everything calculated to excite or increase irritation of the bladder during the sittings. Formerly, when the operations were long, or repeated at short intervals, irritative fever was of much more frequent occurrence than it is now. The treatment of this accident is modified chiefly according to the severity of the symptoms. Many practitioners give a dose of opium after the first sitting, as a means of diminishing the tendency to rigor; and, with the same object, Sir B. Brodie recommends a warm bed, with a tumbler of brandyand-water. Our principal remedies are, of course, such as are best suited to calm the local irritation, on which the irritative fever depends. This fever often puts on the intermittent type, commencing with rigors, ending with perspirations, and appearing at tolerably certain intervals; and this form usually yields to quinine. The reason why this irritative fever is so apt to assume the remittent or even the intermittent type is unknown to us, but the same forms prevail after irritation of the urethra produced by simple sounding or the passage of the catheter. The irritation of a calculous bladder, increased by frequent manipulations, may pass quickly into inflammation, in which case we have fever of a different kind. We have at first the same rigors, feverish paroxysms, and perspirations as in the former kind, but the attack soon becomes more permanent, and the peculiar signs of local inflammation are superadded; or the inflammatory fever may assume a very different form, likely to deceive the most observant practitioner. In these cases, the initial rigors are irregular, or may be absent altogether; the fever is not high, but it is continuous; there are no perspirations ; the signs of vesical disease are not very prominent, yet the patient rapidly sinks. Latent disease of the kidney has probably been developed under the influence of the operation. The most violent fever which occurs during lithotrity is that which is symptomatic of acute cystitis, but this is fortunately The fever in these cases is of the pure inflammatory rare. type: the skin is hot, the tongue dry, the pulse quick, above 120. This state continues for a short time only, for unless the inflammation be speedily arrested, symptoms of sinking set in, the pulse becomes small and weak, there is delirium, and, after the most intense local suffering, the patient dies in a state of coma. The severity and continuous type of this febrile attack, in conjunction with the local symptoms, will serve to distinguish it from any other form. But, dangerous as is the symptomatic fever of acute cystitis, the danger of pysemic fever is much greater, while the difficulty of forming a correct diagnosis can only be appreciated by those who have had to deal with this unfortunate complication. I shall reserve the consideration of this subject until I treat of the causes of death after lithotrity: amongst these severe an
pyaemia, occupies a prominent place. CLINICAL REMARKS, BY DR. BRINTON, AT THE ROYAL FREE HOSPITAL. CHLOROSIS AS A CAUSE OF VENOUS OBSTRUCTION. "
WE have here a case, interesting far beyond its rarity, from the relations, both scientific and practical, which it and its congeners have for some time suggested to me. " The patient, a young woman of twenty-two, came in three weeks ago, with symptoms of extreme prostration and debility, attended with dyspnoea, palpitation, and slight cough. Her
164
scanty from the very beginning of her illness six or months ago, had for the last four periods ceased. She was thought, she told us, to be consumptive by one physician; A few days before was accused of diseased heart by another. admission she was seized with severe pain in the right ham, soon followed by swelling and tenderness of the right leg below the knee, rendering her unable to put her foot to the ground. The lungs, on examination, seemed quite healthy; devoid even of those equivocal signs which it is the fashion to dignify into a’ pre-tubercular state.’ The heart was weak, with a soft systolic and aortic bellows-sound, which, though of great in. tensity, suggested no valvular lesion. Her emaciated (or rather flaccid and almost prematurely wrinkled) condition was associated with a colour better described as a fallow-white, than as the white or greenish hue of ordinary chlorosis. Her pulse and were about 100, and 24, in the minute respectively. breathing " We will not attempt to’beat the bounds’ of chlorosis and leucocythasmia, or to launch into controversial pathology. Nor need I dwell on the details which seemed to exclude the heart and the lungs respectively from all but a secondary rank in the patient’s malady. Perhaps, however, I may say that the mere intensity of a bellows-sound is (unless extreme) a bad guarantee for its valvular origin; which, again, is better suggested by a long (as during systole, diastole, and pause) and unvarying (as during sleep and excitement) character of the murmur. Further, the great increase in the pulmonic exhalation of car. bonic acid in the chlorotic state implies, I think, an activity of the lungs; such as causes a noisy, and sometimes even irregular, style of respiration, in itself decidedly suspicious or equivocal, as resembling (until you sum up all the regions of such a chest) the local irregularities and compensations of tubercular deposit obstructing certain parts of the lungs only. "Keeping, then, to the plain, common-sense points of the case, it suggested two chief diagnostic inferences: chlorosis. affecting the system; and a painful, (Bdematous state of the right leg. On examination, the popliteal vein of this leg was found to be hard, swollen, and surrounded by an exquisitely tender infiltration of a semi-solid character. The chief pain and tenderness, localized here, radiated with decreasing intensity down the limb, in pretty close correspondence with the The whole aspect of course of the sural vessels and nerves. the leg reminded one of phlegmasia alba dolens; save that, in addition to its very different localization, the swelling was less smooth, white, and dense-in other words, more akin to ordinary oedema-than that of this malady. Here, then, was a concurrence of chlorosis and popliteal obstruction-we will not say phlebitis, for if we must have a single Greek word, Phlebobyst (venœ obturatio) would be more accurate, and less presuming. And the question I would now notice and answer is,‘Must this concurrence be regarded as a mere coincidence ; or are the two states, the general and local, linked together ?’ " The latter is the alternative I am anxious to affirm and enforce. Without being aware whether I am the first to do so, I wish to call your particular attention to a point of great practical importance in the pathology of chlorosis : to the risk of a coagulation, in some of the larger veins, of part of that fibrin, long known to be present in excess in the blood of chlorotic menses, seven
"
patients. As productive of a kind of phlegniasia dolens, quite distinct in its signs and symptoms (and, unhappily, in its intractability) from the dropsy of this malady, and I think oftenest affecting this very vein (the popliteal), it has been for some time known "
to me.
And
a case or
two of fatal gangrene, and of inflamma-
tion, of the lung-as well as several of pleurisy, and of sudden and alarming dyspnoea, happily recovered from so as to permit
further verification of their local causes-have suggested to the occurrence of similar clots and obstructions in the pulmonary veins as constitutingless frequent, but more dangerous, incidents of the same kind in chlorotic subjects. And while our fever cases in this Hospital have shown me a decided pre. ponderance of females in the phlegmasia dolens which occurs consecutively to this malady, I am inclined to attribute much of that more marked preponderance of female cases noticed by some writers (Mackenzie) to this chlorotic, as well as to the puerperal, variety of the lesion. " Few better illustrations occur to me of the way in which, however unconsciously, working pathologists help each other, than in the confirmation these views of mine have lately received from an excellent Essay,* for which I am indebted to Mr. Humphry, of Cambridge. This distinguished anatomist and surgeon reports from his own practice several valuable * On the Coagulation of the Blood in the Venous System during Life. Macmillan, Cambridge and London, 1859. no
me
they go far to sustain the important deduc- knowledge, necessarily hypothetical, I now venture to bring forthem, I can only now notice as abundantly ward. That the cerebro-spinal fluid occupies that space which exists confirming my own independent views, and in some respects On the fre- I between the inner layer of the arachnoid and the pia mater; with better evidence than I have to offer. quency of the popliteal affection, indeed, he quite anticipates ’, and that, as pointed out by Magendie, the ventricles of the and extends my statement, which only refers to chlorotic ob- brain communicate with this sub-arachnoidal cavity.
cases,
which,
while
tions he bases
on
That the fluid in the sub-arachnoidal spaces, and points of structions of this vein. And though the specific danger of chlorosis which my observations indicate is not dwelt on by confluence, freely communicate with each other, and also with
to notice that several of his cases refer to young females affected with anaemia, or deficient menstruation. Lastly, as respects the pulmonary obstruction, his exact and numerous observations far surpass my own scanty or vague facts, and reduce these latter to a value chiefly bearing on the specific propositions suggested by the case before us. These propositions I may sum up as follows :-That chlorosis has an element of danger, till now, I think, unnoticed-the risk of venous obstruction by the coagulation of fibrin of the blood. That this obstruction, oftener affecting the popliteal veins, sometimes engages the pulmonary arteries, the venous blood of which becomes the seat of coagulation similar to that in the preceding systemic vessels. That sudden and extreme dyapno3a, gangrene, pneumonia, or even pleurisy, occurring in chlorosis, justify a suspicion of some such accident in the pulmonary vessels. That, when localized in a limb, the analogous occurrence can generally be recognised with an ease approaching to certainty. " As to treatanent, the pulmonary cases suggest (and in my own practice have amply repaid) a treatment chiefly by stimulants, a generous regimen, and extreme quiet. The popliteal are, as already hinted, rather intractable. The general treatment of chlorosis, especially by ferruginous tonics and cod-liver oil, is of course all important. As to local remedies, those I have found most useful are : the raising and extension of the leg, as well as its support by careful bandaging; and, in severe cases, acupuncture of the distended areolar tissue some distance below the obstructed vein. The latter remedy seems to be both harmless and efficacious, especially if the limb be allowed slowly to drain off its contents, in a dependent posture, into a flannel bandage kept warm by frequent wringing out of hot waters This procedure is advantageously followed, when the punctures have healed, by gentle friction of the surface, with warm oil, once or twice daily; care being of course taken to use no more pressure than the tenderness of the parts will bear without causing pain. Lastly comes a local remedy which, in some of the oedematous swellings of mere debility, I have found of great advantage, and of considerable (though less) use in phlegmasia dolens generally-viz., steeping the leg in tolerably hot and strong brine (made by adding to each double handful of salt a gallon of hot water) for an hour at a time nightly. In the case before us, I have not thought acupuncture necessary. The patient has regained a good deal of strength, and even of colour. Her pulse and breathing have fallen in frequency to about 80 and 20 per minute. Her cough has disappeared. The leg, too, has greatly diminished in size ; it has become much less tender and painful in its popliteal region, and it allows her to take a fair amount of walking exercise without any pain or limping difficulty. In short, she is far advanced towards recovery."
him, yet it is interesting
ON THE CEREBRO-SPINAL FLUID. BY JOSEPH
WILLIAMS, M.D.
the ventricles of the brain; and further, that the cerebro-spinal fluid readily passes from the cranial sac downwards to envelop the spinal cord, and also upwards from the spinal sheath into the
cranium.
That the central canal in the spinal cord invariably exists, and bears the most evident marks of special design in its peculiar construction. That the intra- and extra-cranial sub-arachnoidal tubes, surrounding the cerebral nerves as they emerge from the cranium, communicate continuously, and directly with the fluid in the large intra-cranial sub-arachnoidal spaces, and consequently, also, with the spinal sub-arachnoidal sac. That the filaments of the roots of the cerebral and spinal nerves may be clearly seen floating in the cerebro-spinal fluid. That the clear fluid which sometimes escapes so abundantly from the ear and from the nose in cranial fractures, is now proved to be cerebro-spinal fluid. That the quantity of the cerebro-spinal fluid is infinitely greater than is usually imagined or described; and that it is
rapidly secreted, but also rapidly renewed. That it is doubtless being constantly secreted, there being a continuous waste, not only with each psychical, but with every physical and reflex action; and that a larger amount of cerebrospinal fluid is probably formed for psychical than for mere physical effort. That it is probably being continuously excreted by cuticular, but especially by renal action. That the cerebro-spinal fluid becomes at once affected,
not only
or poisoned, by alimentary, chemical, therapeutic agents-by whatever, in fact, enters into the
tainted, impregnated, or
circulation.
That the cerebro-spinal fluid actually comes in contact with what we believe to be the most important portions of the cerebro-spinal mass; and that it also probably is distributed throughout the whole of the brain and spinal cord, and even to the minutest peripheric terminations of the nerves. That the quantity of the cerebro-spinal fluid bears an inverse proportion to the size of the cerebro-spinal axis; and that, in obedience to the hydrostatic law, the fluid instantly passes to the point where the resistance is least; but that intracranial compression may actually occur, notwithstanding those numerous and wonderfully designed safeguards for preventing it. That the cerebro-spinal fluid is probably secreted by the cellular portions of the cerebro-spinal mass, or by the pia. mater, and that it is being constantly diffused throughout the whole of the nervous system. That the pia mater not only dips down into the convolutions, as usually described, but that it probably, as a highly vascular and delicately attenuated membrane, penetrates into every portion of the cerebro-spinal mass, wlaerever the arterial blood is distributed. That sea-sickness probably depends upon the irritation caused by the irregular and unequal vibratory pulsations or undulations of the cerebro-spinal fluid, as also the antiperistaltic action so frequently observed in hydrocephalus, as well as the less frequent intussusception. That the alternate rise and fall of the cerebro-spinal fluid does not synchronize with the pulsations of the heart, but corresponds with the movements of respiration, there being and exhaustion, and hence the an alternate compression dynamic power for sustaining the circulation of the cerebrospinal fluid. That undulatory motions or currents exist.in all the cavities of the brain and spinal cord. That in addition to the cerebro-spinal fluid forming a " water bed" on which the cerebro-spinal mass can float, and thus be protected from friction and concussion, and in which its nutrient bloodvessels can also be protected from any direct pressure, that it is also probably destined to pervade and moisten every portion of the nervous system. That when this fluid is deficient, perverted, or desiccated, it may cause a partial or more complete paralysis, as also atrophic wasting of the muscles; moisture being so essential for all nervous action. That the local pain of gout depends not only upon the irri’
’
NEARLY five-and-twenty years have now glided by since my attention was first specially directed to the secretion and probable uses of the cerebro-spinal fluid, by reading in THE LANCET On an account of the interesting experiments of Magendie. the following session I attended a course of his lectures at the College Royal de France, and ever since that period my inquiries have been, from time to time, devoted to this abstruse and complicated subject. Desirous that the views now promulgated may be duly tested, weighed, and sifted, I place them in the pages of THE LANCET, in order that other opinions may be elicited as to their validity. Some of the suggestions may at first appear somewhat startling, although upon patient investigation they will, I believe, gradually become more and more feasible. The following statements, then, some of which we know to be matters of fact, while others are, in our present state of
’
165
rigors and subsequent evident effect of our doing too much at a time; while the subsequent attacks are often as clearly kept up and increased whenever our operative proceedings are of a nature to irritate the bladder, or when the detritus is abundant and not readily discharged. I consider the fever to be irritative, and not inflammatory, for it sometimes appears immediately after the first operation; and although the first attacks may be severe, they often disappear in two or three days under palliative treatment. Again, in some patients of a nervous and irritable temperament, each sitting, however short, gives rise to an attack of fever, often preceded by rigors, but the febrile symptoms disappear in a few hours. Lastly, a febrile attack of the same kind as that now described, which may be severe, and continue for several days, is sometimes excited, in spite of every caution, by simple examination with the sound or catheter. The practical conclusion to be drawn from the nature and causes of this fever is, that, to prevent it, we should avoid everything calculated to excite or increase irritation of the bladder during the sittings. Formerly, when the operations were long, or repeated at short intervals, irritative fever was of much more frequent occurrence than it is now. The treatment of this accident is modified chiefly according to the severity of the symptoms. Many practitioners give a dose of opium after the first sitting, as a means of diminishing the tendency to rigor; and, with the same object, Sir B. Brodie recommends a warm bed, with a tumbler of brandyand-water. Our principal remedies are, of course, such as are best suited to calm the local irritation, on which the irritative fever depends. This fever often puts on the intermittent type, commencing with rigors, ending with perspirations, and appearing at tolerably certain intervals; and this form usually yields to quinine. The reason why this irritative fever is so apt to assume the remittent or even the intermittent type is unknown to us, but the same forms prevail after irritation of the urethra produced by simple sounding or the passage of the catheter. The irritation of a calculous bladder, increased by frequent manipulations, may pass quickly into inflammation, in which case we have fever of a different kind. We have at first the same rigors, feverish paroxysms, and perspirations as in the former kind, but the attack soon becomes more permanent, and the peculiar signs of local inflammation are superadded; or the inflammatory fever may assume a very different form, likely to deceive the most observant practitioner. In these cases, the initial rigors are irregular, or may be absent altogether; the fever is not high, but it is continuous; there are no perspirations ; the signs of vesical disease are not very prominent, yet the patient rapidly sinks. Latent disease of the kidney has probably been developed under the influence of the operation. The most violent fever which occurs during lithotrity is that which is symptomatic of acute cystitis, but this is fortunately The fever in these cases is of the pure inflammatory rare. type: the skin is hot, the tongue dry, the pulse quick, above 120. This state continues for a short time only, for unless the inflammation be speedily arrested, symptoms of sinking set in, the pulse becomes small and weak, there is delirium, and, after the most intense local suffering, the patient dies in a state of coma. The severity and continuous type of this febrile attack, in conjunction with the local symptoms, will serve to distinguish it from any other form. But, dangerous as is the symptomatic fever of acute cystitis, the danger of pysemic fever is much greater, while the difficulty of forming a correct diagnosis can only be appreciated by those who have had to deal with this unfortunate complication. I shall reserve the consideration of this subject until I treat of the causes of death after lithotrity: amongst these severe an
pyaemia, occupies a prominent place. CLINICAL REMARKS, BY DR. BRINTON, AT THE ROYAL FREE HOSPITAL. CHLOROSIS AS A CAUSE OF VENOUS OBSTRUCTION. "
WE have here a case, interesting far beyond its rarity, from the relations, both scientific and practical, which it and its congeners have for some time suggested to me. " The patient, a young woman of twenty-two, came in three weeks ago, with symptoms of extreme prostration and debility, attended with dyspnoea, palpitation, and slight cough. Her
164
scanty from the very beginning of her illness six or months ago, had for the last four periods ceased. She was thought, she told us, to be consumptive by one physician; A few days before was accused of diseased heart by another. admission she was seized with severe pain in the right ham, soon followed by swelling and tenderness of the right leg below the knee, rendering her unable to put her foot to the ground. The lungs, on examination, seemed quite healthy; devoid even of those equivocal signs which it is the fashion to dignify into a’ pre-tubercular state.’ The heart was weak, with a soft systolic and aortic bellows-sound, which, though of great in. tensity, suggested no valvular lesion. Her emaciated (or rather flaccid and almost prematurely wrinkled) condition was associated with a colour better described as a fallow-white, than as the white or greenish hue of ordinary chlorosis. Her pulse and were about 100, and 24, in the minute respectively. breathing " We will not attempt to’beat the bounds’ of chlorosis and leucocythasmia, or to launch into controversial pathology. Nor need I dwell on the details which seemed to exclude the heart and the lungs respectively from all but a secondary rank in the patient’s malady. Perhaps, however, I may say that the mere intensity of a bellows-sound is (unless extreme) a bad guarantee for its valvular origin; which, again, is better suggested by a long (as during systole, diastole, and pause) and unvarying (as during sleep and excitement) character of the murmur. Further, the great increase in the pulmonic exhalation of car. bonic acid in the chlorotic state implies, I think, an activity of the lungs; such as causes a noisy, and sometimes even irregular, style of respiration, in itself decidedly suspicious or equivocal, as resembling (until you sum up all the regions of such a chest) the local irregularities and compensations of tubercular deposit obstructing certain parts of the lungs only. "Keeping, then, to the plain, common-sense points of the case, it suggested two chief diagnostic inferences: chlorosis. affecting the system; and a painful, (Bdematous state of the right leg. On examination, the popliteal vein of this leg was found to be hard, swollen, and surrounded by an exquisitely tender infiltration of a semi-solid character. The chief pain and tenderness, localized here, radiated with decreasing intensity down the limb, in pretty close correspondence with the The whole aspect of course of the sural vessels and nerves. the leg reminded one of phlegmasia alba dolens; save that, in addition to its very different localization, the swelling was less smooth, white, and dense-in other words, more akin to ordinary oedema-than that of this malady. Here, then, was a concurrence of chlorosis and popliteal obstruction-we will not say phlebitis, for if we must have a single Greek word, Phlebobyst (venœ obturatio) would be more accurate, and less presuming. And the question I would now notice and answer is,‘Must this concurrence be regarded as a mere coincidence ; or are the two states, the general and local, linked together ?’ " The latter is the alternative I am anxious to affirm and enforce. Without being aware whether I am the first to do so, I wish to call your particular attention to a point of great practical importance in the pathology of chlorosis : to the risk of a coagulation, in some of the larger veins, of part of that fibrin, long known to be present in excess in the blood of chlorotic menses, seven
"
patients. As productive of a kind of phlegniasia dolens, quite distinct in its signs and symptoms (and, unhappily, in its intractability) from the dropsy of this malady, and I think oftenest affecting this very vein (the popliteal), it has been for some time known "
to me.
And
a case or
two of fatal gangrene, and of inflamma-
tion, of the lung-as well as several of pleurisy, and of sudden and alarming dyspnoea, happily recovered from so as to permit
further verification of their local causes-have suggested to the occurrence of similar clots and obstructions in the pulmonary veins as constitutingless frequent, but more dangerous, incidents of the same kind in chlorotic subjects. And while our fever cases in this Hospital have shown me a decided pre. ponderance of females in the phlegmasia dolens which occurs consecutively to this malady, I am inclined to attribute much of that more marked preponderance of female cases noticed by some writers (Mackenzie) to this chlorotic, as well as to the puerperal, variety of the lesion. " Few better illustrations occur to me of the way in which, however unconsciously, working pathologists help each other, than in the confirmation these views of mine have lately received from an excellent Essay,* for which I am indebted to Mr. Humphry, of Cambridge. This distinguished anatomist and surgeon reports from his own practice several valuable * On the Coagulation of the Blood in the Venous System during Life. Macmillan, Cambridge and London, 1859. no
me
they go far to sustain the important deduc- knowledge, necessarily hypothetical, I now venture to bring forthem, I can only now notice as abundantly ward. That the cerebro-spinal fluid occupies that space which exists confirming my own independent views, and in some respects On the fre- I between the inner layer of the arachnoid and the pia mater; with better evidence than I have to offer. quency of the popliteal affection, indeed, he quite anticipates ’, and that, as pointed out by Magendie, the ventricles of the and extends my statement, which only refers to chlorotic ob- brain communicate with this sub-arachnoidal cavity.
cases,
which,
while
tions he bases
on
That the fluid in the sub-arachnoidal spaces, and points of structions of this vein. And though the specific danger of chlorosis which my observations indicate is not dwelt on by confluence, freely communicate with each other, and also with
to notice that several of his cases refer to young females affected with anaemia, or deficient menstruation. Lastly, as respects the pulmonary obstruction, his exact and numerous observations far surpass my own scanty or vague facts, and reduce these latter to a value chiefly bearing on the specific propositions suggested by the case before us. These propositions I may sum up as follows :-That chlorosis has an element of danger, till now, I think, unnoticed-the risk of venous obstruction by the coagulation of fibrin of the blood. That this obstruction, oftener affecting the popliteal veins, sometimes engages the pulmonary arteries, the venous blood of which becomes the seat of coagulation similar to that in the preceding systemic vessels. That sudden and extreme dyapno3a, gangrene, pneumonia, or even pleurisy, occurring in chlorosis, justify a suspicion of some such accident in the pulmonary vessels. That, when localized in a limb, the analogous occurrence can generally be recognised with an ease approaching to certainty. " As to treatanent, the pulmonary cases suggest (and in my own practice have amply repaid) a treatment chiefly by stimulants, a generous regimen, and extreme quiet. The popliteal are, as already hinted, rather intractable. The general treatment of chlorosis, especially by ferruginous tonics and cod-liver oil, is of course all important. As to local remedies, those I have found most useful are : the raising and extension of the leg, as well as its support by careful bandaging; and, in severe cases, acupuncture of the distended areolar tissue some distance below the obstructed vein. The latter remedy seems to be both harmless and efficacious, especially if the limb be allowed slowly to drain off its contents, in a dependent posture, into a flannel bandage kept warm by frequent wringing out of hot waters This procedure is advantageously followed, when the punctures have healed, by gentle friction of the surface, with warm oil, once or twice daily; care being of course taken to use no more pressure than the tenderness of the parts will bear without causing pain. Lastly comes a local remedy which, in some of the oedematous swellings of mere debility, I have found of great advantage, and of considerable (though less) use in phlegmasia dolens generally-viz., steeping the leg in tolerably hot and strong brine (made by adding to each double handful of salt a gallon of hot water) for an hour at a time nightly. In the case before us, I have not thought acupuncture necessary. The patient has regained a good deal of strength, and even of colour. Her pulse and breathing have fallen in frequency to about 80 and 20 per minute. Her cough has disappeared. The leg, too, has greatly diminished in size ; it has become much less tender and painful in its popliteal region, and it allows her to take a fair amount of walking exercise without any pain or limping difficulty. In short, she is far advanced towards recovery."
him, yet it is interesting
ON THE CEREBRO-SPINAL FLUID. BY JOSEPH
WILLIAMS, M.D.
the ventricles of the brain; and further, that the cerebro-spinal fluid readily passes from the cranial sac downwards to envelop the spinal cord, and also upwards from the spinal sheath into the
cranium.
That the central canal in the spinal cord invariably exists, and bears the most evident marks of special design in its peculiar construction. That the intra- and extra-cranial sub-arachnoidal tubes, surrounding the cerebral nerves as they emerge from the cranium, communicate continuously, and directly with the fluid in the large intra-cranial sub-arachnoidal spaces, and consequently, also, with the spinal sub-arachnoidal sac. That the filaments of the roots of the cerebral and spinal nerves may be clearly seen floating in the cerebro-spinal fluid. That the clear fluid which sometimes escapes so abundantly from the ear and from the nose in cranial fractures, is now proved to be cerebro-spinal fluid. That the quantity of the cerebro-spinal fluid is infinitely greater than is usually imagined or described; and that it is
rapidly secreted, but also rapidly renewed. That it is doubtless being constantly secreted, there being a continuous waste, not only with each psychical, but with every physical and reflex action; and that a larger amount of cerebrospinal fluid is probably formed for psychical than for mere physical effort. That it is probably being continuously excreted by cuticular, but especially by renal action. That the cerebro-spinal fluid becomes at once affected,
not only
or poisoned, by alimentary, chemical, therapeutic agents-by whatever, in fact, enters into the
tainted, impregnated, or
circulation.
That the cerebro-spinal fluid actually comes in contact with what we believe to be the most important portions of the cerebro-spinal mass; and that it also probably is distributed throughout the whole of the brain and spinal cord, and even to the minutest peripheric terminations of the nerves. That the quantity of the cerebro-spinal fluid bears an inverse proportion to the size of the cerebro-spinal axis; and that, in obedience to the hydrostatic law, the fluid instantly passes to the point where the resistance is least; but that intracranial compression may actually occur, notwithstanding those numerous and wonderfully designed safeguards for preventing it. That the cerebro-spinal fluid is probably secreted by the cellular portions of the cerebro-spinal mass, or by the pia. mater, and that it is being constantly diffused throughout the whole of the nervous system. That the pia mater not only dips down into the convolutions, as usually described, but that it probably, as a highly vascular and delicately attenuated membrane, penetrates into every portion of the cerebro-spinal mass, wlaerever the arterial blood is distributed. That sea-sickness probably depends upon the irritation caused by the irregular and unequal vibratory pulsations or undulations of the cerebro-spinal fluid, as also the antiperistaltic action so frequently observed in hydrocephalus, as well as the less frequent intussusception. That the alternate rise and fall of the cerebro-spinal fluid does not synchronize with the pulsations of the heart, but corresponds with the movements of respiration, there being and exhaustion, and hence the an alternate compression dynamic power for sustaining the circulation of the cerebrospinal fluid. That undulatory motions or currents exist.in all the cavities of the brain and spinal cord. That in addition to the cerebro-spinal fluid forming a " water bed" on which the cerebro-spinal mass can float, and thus be protected from friction and concussion, and in which its nutrient bloodvessels can also be protected from any direct pressure, that it is also probably destined to pervade and moisten every portion of the nervous system. That when this fluid is deficient, perverted, or desiccated, it may cause a partial or more complete paralysis, as also atrophic wasting of the muscles; moisture being so essential for all nervous action. That the local pain of gout depends not only upon the irri’
’
NEARLY five-and-twenty years have now glided by since my attention was first specially directed to the secretion and probable uses of the cerebro-spinal fluid, by reading in THE LANCET On an account of the interesting experiments of Magendie. the following session I attended a course of his lectures at the College Royal de France, and ever since that period my inquiries have been, from time to time, devoted to this abstruse and complicated subject. Desirous that the views now promulgated may be duly tested, weighed, and sifted, I place them in the pages of THE LANCET, in order that other opinions may be elicited as to their validity. Some of the suggestions may at first appear somewhat startling, although upon patient investigation they will, I believe, gradually become more and more feasible. The following statements, then, some of which we know to be matters of fact, while others are, in our present state of
’
165