With one exception the patients were all lunatics. The following is his description of that case.

A woman, an inmate of the House of Industry, died of bronchitis and pneumonia. She had incomplete paralysis and atrophy of the left arm from her infancy, with a permanently flexed condition of the arm, and of the hand on the forearm. The fingers were also flexed on the hand. Her head was small, though well formed. The left upper and lower extremities were wasted. She was endowed with ordinary intelligence, and all her senses were perfect.

Upon removing the dura mater the right hemisphere of the brain was found to be atrophied; the convolutions of the anterior and posterior lobes alone existed, and these were remarkably firm and hard, and exceedingly small. The convolutions of the middle lobe were for the most part deficient, and their place was supplied by the arachnoid membrane, which thus formed a great portion of the outer wall of the lateral ventricle. This cavity was considerably dilated, and filled with serum. The right was not more than one fifth of the size of the left hemisphere. The optic thalamus was not larger than a small nut, and extremely hard. Its inner edge presented a puckered appearance. The corpus striatum, crus cerebri, and corpus mamillare of the right side were also atrophied.*

The specimens of the other cases are all similar. The spinal cord in all of them was healthy, and in most of them nothing but a fold of arachnoid membrane intervened between the fluid in the ventricle and the cavity of the arachnoid.

Cruveilhier gives a case+ similar to this. The right side was incompletely paralysed, the patient was endowed with ordinary intellect. The left hemisphere of the brain was atrophied, without any organic lesion. How, says Cruveilhier, is this fact to be reconciled with other facts of daily occurrence, which exhibit small effusions, small tumours in the brain, producing complete hemiplegy of sensation and of motion ? The cause perhaps exists in the difference existing partly between atrophy of the brain by compression, and atrophy without compression, and partly between this atrophy, no matter what its cause, and solution of continuity, or the interruption of the cerebral fibres. In atrophy the instrument of our sensation and volition is doubtless imperfect; but it exists with all its constituent parts, which fulfil well or ill the functions they are called on to perform. In solution of continuity, on the contrary, a certain number of the medullary fasciculi of the brain are incapable of transmitting the orders of the will and external impressions;-there is a hiatus, an interval that nothing can surmount. In this case there was a deficiency of nutrition of the brain, which, he states, was as developed as possible. In * Dublin Medical Journal, Vol. xvii., p. 341. † L. c., Livr. viii., Planche v.

Smith's case there was absence of a portion of the brain, yet both patients were endowed with ordinary intelligence.

There are many cases of hydrocephalus in which there existed no paralysis of the limbs, and in which the intellect was not much affected; yet it does not therefore follow there was in them no deficiency of any portion of the brain. In the cases given by Mr Paget and Mr M. Henry, although the corpus callosum, septum lucidum, and the fornix were defective, there was no absolute want of any function of the brain. "It is worthy of remark," says Mr Henry,* "that my patient in several particulars exhibited a complete antithesis to the girl who fell under Mr Paget's notice. Neither of them can be said to have been of healthy mind, and yet the mental deficiency was of an opposite character in each. In the girl the peculiarity was 'vivacity and a want of caution, showing themselves in an habitual rapidity of action and want of forethought, deliberation, and attention; whilst in the boy it was a disproportionate degree of caution and want of vivacity, showing themselves in an extreme slowness, amounting almost to stupidity."

Having now shown that hydrocephalic patients will survive for years without the operation of tapping the head being employed with them, but if they do they continue a burden to themselves and their friends, I may add I know of no remedy for so unfortunate a condition. Portal's remarks on this subject are very apposite. "What remedy," says he, "would be efficacious for curing dropsies of the brain, when, independently of the water inundating this viscus, it is disorganised in its substance, and to such a degree that it often forms nothing but a soft mass like bouillie, in which it is impossible to make out a difference between the cortical and medullary structures? The cautery, which has been employed for opening the cranium of a hydrocephalic child, has not had more fortunate success than the operation of tapping, and how could it? The sole sinking in by its own weight of the medullary structure (even were it quite sound) upon itself, would it not produce death? The evacuation of the water procured by the operation, would it destroy the causes which produced it, and which will again produce it ?"

Dublin, 31 Kildare Street.

• Med.-Chir. Trans., Vol. xxxi., p. 239. † Anatomie Medicale, T. iv., p. 76,

ART. II.-Clinical Contributions to the Investigation and Treatment of General Disease; being Extension of an Introductory Lecture. By CHARLES RITCHIE, M.D., Fellow of the Faculty of Physicians and Surgeons of Glasgow, and one of the Physicians to the Royal Infirmary, Glasgow.

Ir devolves on me, as the senior physician for the time being of this hospital, to be the first to address you here, on the occasion of the opening of another winter session. In attempting to fulfil this duty, my most prominent feeling is that of cordial sympathy with you as fellow-members with me of a common profession, committed equally, one with the other, to the vigorous, wise, and sustained performance of similar duties, and to the intelligent but patient and persevering endurance of kindred difficulties. As clinical students, you are no longer to be regarded as occupied in the acquisition of rudimentary knowledge only, but as advanced to the position of being called to test, by a process of personal investigation, the validity of the general abstract principles you already know. You are presumed to be possessed in the synthetical forms in which these are necessarily communicated in all preceptive teaching, of a knowledge of the great axiomatic truths connected with disease; and, as hospital students, you are now understood to enter on the analysis of your previous erudition, by a humble, untiring, exact, and varied reference to practical and real life. In speaking thus, I do not forget that, as clinical students, you are only, indeed, rehearsing, in indulgent seclusion, those mental efforts which the actual practitioner has to execute under the heavy and continued pressure of multiplied and diversified living interests; but neither do I cease to remember that one of the most imperative and permanent of the obligations which rest on the practitioner, is, that, however advanced in years or acquirements, he shall continue to be a student; and therefore it is that, in clinical tuition, I regard the relations of the teacher with the taught as being more properly those of a fellow-observer, than as inferring, on his part, a character which is purely didactic.

The immediate department of our profession to which this lecture is designed to be specially introductory, is Clinical Medicine, or the science of the observation, study, and treatment of internal or of constitutional disease. How obvious is it, then, at the outset, that the physician who would guide your researches in such a field as this, must himself be an assiduous inquirer, and that both he and you, in order to profit in so onerous a work, must be competent, not only as observers, but also in a capacity to attach a correct scientific import to what we do see, and also, each in our

respective spheres, be able to deduce from the materials, so collected and classified, a rational and successful treatment.

It is this latter view of the subject, indeed, or the continued demand which is made on us in clinical medicine for the exercise of thought, which, whether I regard it as a practitioner or as a teacher, invests our employment in these wards, in my estimation, with its principal interest. In the former relation, I perceive in the occupant of every bed, the subject of an important species of analysis, the materials for a succession of momentous, and sometinies profound, problems in pathology and therapeutics; and in the latter, or as having the honour to aid in guiding this department of your studies, I realise in the extended field for clinical and necroscopical observations which this hospital affords, and in the other facilities for its cultivation which are placed at our disposal, an invaluable and deeply responsible opportunity of at least attempting to train minds which must soon influence the destinies of multitudes, in such a manner as may most speedily and safely accustom you to observe and to think for yourselves.

It may form no unsuitable method of illustrating these obser vations, to turn at once to the realities of an actual case.

In giving a judgment on the nature of an individual example of disease, the first practical difficulty met with is the determination of its facts. These are rarely limited in medical, and especially in chronic cases, to the immediate circumstances of the attack. They extend often to the organic, the moral, and the social condition of the patient; and the observer, in conducting his examination, is guided more or less systematically and consciously by these relations. Here, then, we are supplied at the very threshold of our inquiries with an obvious general classification of the elements of the investigation into those which refer,

1st, To the moral and social conditions of the patient. 2d, To his physical aspect and state; and,

3d, To the history of his illness.

In proceeding with the inquiry, a second object will be to lay hold of and to group the facts which are essential to the particular case, and which explain its character. At this point the exploration may become narrowed or enlarged, or assume one or other of an infinite number of possible forms, according to circumstances; but no key to the explication of the generic nature of the morbid state under review can ever be found, unless by successively questioning each of the three general classes of facts I have named, under more or fewer of the following particulars.

CLASS I.-The moral and social condition of the patient. 1. Name and surname.-Here the element of sex, modifying every circumstance of the case, meets us at the outset.

This is particularly true of the female. There is no organ which excites more multiplied, powerful, or varied sympathies throughout the economy than the uterus, nor is there any class of facts the knowledge of which is more limited to the experienced practitioner, or regarding which less practised persons are more frequently mistaken. The countenance, complexion, aspect of the eyes, of the neck, the sounds of the heart and arteries, the shape, postures, and manner of walking, and the functional disturbances of the stomach, spinal and crural nerves, and of the bladder of urine, in the female, readily and correctly suggest to those who are suitably instructed the necessity of inquiry into the condition of the uterus. There is no doubt that a physician who has been awakened to a sense of the tendency to overlook uterine disease, but whose notions on the subject have not been balanced by the corrective power of an extended experience of its phenomena, runs some hazard of seeing more in the condition of the womb on such occasions than is accordant with sober fact. The same is true, although from other causes, of the man whose practice is limited to the female sexual organs; and it may safely be asserted, besides, that no order of patients can more readily be betrayed into the adoption of the opinion of their physician, by a leading question or two, than can women into the belief of their being the subjects of uterine disease. Still, the high diagnostic importance of the question of sex is undoubted, and its bearing on the subject of prognosis is often not less real. Thus, the greater longevity of females than of males is well known, as is also the relatively low mortality from acute diseases in the nonpuerperal, and its frightfully high amount in many of the same complaints in the puerperal female. A curious circumstance connected with prognosis in a number of cases is, that if your patient be a young man, his restorative powers will, with ordinary care, remove him out of your hands in a few days, while in the unmarried female above puberty, recovery takes place with great difficulty, in an imperfect manner, and only after a protracted attendance.

The greater susceptibility of the female adult, and specially when newly delivered, to contagion, than the male, is another aspect of the question of sex which deserves to be remembered. The rise of many an instance of child-bed fever is thus found in the simultaneous attendance of the accoucheur on some patient labouring under erysipelas, or certain surgical diseases, or in the dissecting room; and the same line of communication by the medical attendant is too often the true one in regard to attacks of scarlatina and typhus in the same circumstances. The tendency to such occurrences is greatly increased when the practitioner is conveyed from the one description of patient to the other in a covered

VOL LXXV. No. 186.

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