No.815.

LONDON, SATURDAY, APRIL 13, 1839. [1838-39.

CLINICAL LECTURES,DELIVERED AT UNIVERSITY COLLEGE HOSPITAL,

BY

ROBERT CARSWELL, M.D.,Professor of Pathological Anatomy in Uni-

versity College, London; and of ClinicalMedicine in University College Hospital.

ECZEMA IMPETIGINODES,

AKU REMARKS ON TilE CONTAGIOUS AND Not-

CONTAGIOUS PUSTULAR AFFECTIONS OF THE

HEAD.

GENTLEMEN :-Before relating to you thehistories of two cases of eczema impetigi-nodes which have been under your observa-tion, both patients having now left the hos-pital cured, I shall make a few remarks onthe elementary characters of this cutaneousaffection, that you may have a more clearconception of those characters, as the onlymeans of enabling you to recognise the dis-ease when you meet with it, in its differentforms, and on different parts of the body,and thereby distinguish it from other simi-lar cutaneous diseases with which it is so

frequently confounded, and from which itdifl*ers in one most essential particular,viz., its non-contagious nature; and thisappears to me the more necessary because ofthe imperfect acquaintance which not onlystudents, but even most medical men, pos-sess of cutaneous diseases generally, andbecause of the importance of an accaratediagnosis, more especially as regards thosepustular forms of cutaneous disease whichare propagated by contagion.

In order to impress on your minds the im-portance of an accurate diagnosis of skin

diseases, I may further observe that it is thefirst and most essential means of acquiringa knowledge of their history and treatment.;for as it is. in general, by an accurate appre-ciation of their physical characters that youcan obtain their respective designations andnames. so is it from this latter circumstancethat you can refer to those standard worksin which you are to find the result of theexperience of those who have studied thesediseases in aa especial masner. In this

point of view alone an accurate diagnosis.if not as important as regards the issue ofthe case, as it always is in diseases affectingthose organs essential to the maintainanceof lifr, is often much more so all regards thereputation of the practitioner ; as, for ex-ample, when he pronounces a disease of theskin to he non-contagious which very soonafter is communicated to other members of afamily, or to the other inmates of a school ;or, on the other hand, his pronouncing adisease to he contagious which is not so,and in consequence of his erroneOQS diagno.sis giving rise to great disquietude, and in.nicting too frequently a great injury on hispatient, as happens to children at school,whose removal follows as a necessary con-

sequence.These latter observationsapply more espe-

cially to the pustular and vesiculo-pustularaffections of the scalp, some of which arecontagious, others not, and which, althonghin almost all cases their special and distinc-tive characters are sufficiently well markedto furnish us with the elements of an accu-rate diagnosis, are frequently, nay daily,confounded with each other.However frequent the contagious forms of

pustular allections ot the head are believedto be, it is an important fact that the non-tagious forms are extremely frequent. Per-haps I would be justified in saying that theyare much more treqnent than the former ;for among the considerable number of caseswhich I have had occasion to treat among theout-patients of this hospital, there have beenextremely few of a contagious nature. In-deed, I believe I have had only two casesof contagious pustular diseafe of the head,viz., the porrigo scutulata, more commonly,but indetinitely, called ringworm, and cer-tainly not a single case of porrigo favosa.As I shall, no doubt, have the opportunity

of bringing under your notice, at some fu-ture period, the subject of pustular diseasesof the skin, in their contagious forms, I shallnot at present enter into a description oftheir special elementary characters. It will.besides, be sufficient for our present pur-pose to notice the distinctive characters ofthese as a mean,; of giving prtcision andprominency to those sebich usually charac-

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terise the non-contagious pustular affections erythematons redness accompanied by a con-presented by the two patients whose cases I siderable discharge. Besides these appear-have to relate to you. ances of the head and ears there were alsoAud, in the first place, what are the ele- redness, swelling, and excoriation of the

mentary characters of eczema impetiginodes ? nates. There was little or no disturbance ofThis disease, as the term implies. is a corn- the general health.pound of two diseases,-of eczema and of This is an extremely simple and obviousimpetigo, Now, each of these, in its sepa- case of two forms of eczema, viz., eczemarate state, has its own elementary character impetiginodes of the scalp, and of eczema—a vesicle in eczema, and a pustule in im- rubrum of the ears and nates. The vesiculo-petigo. In eczema impetiginodes we have pustular eruption of the scalp, in the first

both, the vesicle and the pustule ; the vesi- stage of the disease, and the incrustationscle, however, being the’primary element, and formed by the discharge of the secreted

generally predominating during the early fluids in the second stage, were well marked,stage of the disease. And, besides, the pus- and without those complications which arisetular character of this affection always suc- from the long duration of the disease, a badceeds to the vesicular, and can easily be state of the general health, and neglect oftraced during its progress to a change in the cleanliness. The characters of the eczemacontents of the vesicle, which consisting, at rubrum behind the ears and on the nates

first, of a clear yellow-coloured serosity, were less perfect, as the vesicular elementafterwards becomes milky-looking, opaque, was absent, as generally happens on the de-and puriform. In most cases, however, of cline of the disease, there remaining onlyeczema impetiginodes the pustular element the bright-red colour of the skin from whichis much less perfect than the vesicular, the it derives its name, with a few thin, lami-contents of the former consisting of a sero- nated, transparent incrustations, formed bypurulent, rather than of a purulent fluid, the morbid secretion of the inflamed cutisBut in cases in which the inflammation is deprived of the epidermis. In this stage ofmore severe than usual, the perfect impeti- the affection it resembles, and is sometimesginous pustule is formed; that is to say, the denominated, intertrigo, which, however, issmall, psydraceous pustule, characteristic of only a variety of erythema, produced byimpetigo, and even the large or phylaceous friction of contiguous parts, as between thepustule, characteristic of ecthyma. thighs and nates of fat children, for example.Such are the special and distinctive cha- This case terminated favourably in about

racters of eczema impetiginodes. The pus- three weeks after the admission of the littletular character of this form of eczema dis- patient, under the use of a mild antiphlogis-tinguishes it from the other forms of the tic treatment, such as is always indicateddisease, viz., from the eczema simplex, and required in recent cases of this nature.which is a purely vesicular eruption, neither After the removal of the hair, poulticespreceded nor accompanied by redness of the were employed with a twofold intention,skin ; and from eczema .rubrum, which is viz., to facilitate the removal of the incrusta-always distinguishable by the bright-red tions and diminish the inflammatory excite-colour of the skin,and the number of minute mentwhich accompanies the eruption. Thisvesicles by which it is covered. To distin- latter intention was also fulfilled by water-guish eczema impetiginodes from some other dressings behind the ears. The bowelsdiseases of the skin is not always so easily were regulated, at first, by means of calomelaccomplished, and this is more especially and rhubarb, and afterwards by the com-the case in that form of scabies, called sca- pound decoction of aloes and tincture ofbies purulenta, affecting the fingers and senna. The local atlection improved daily,hands, parts, also, often affected with ec- and the redness and slight discharge thatzema impetiginodes. But as these parts still remained were nearly removed by thewere not affected in either of our patients, I application of a lotion of the dilate liquorshall notice only those circumstances which plumbi, when the child was removed at thedistinguish this disease more especially desire of her mother.from porrigo of the scalp, and on other ’I’o make any remarks on the distinctiveparts of the body. But I shall first read to characters of this case of eczema impetigi-you the short case of Charlotte Fuller, ad- nodes of the head, and other diseases ofmitted on the lst of January, with eczema this part of the body, would certainly beimpetiginudes. She was a female child, two superfluous as regards the diagnosis of thisyears of age, in general good health, and individual case, so simple and obvious wereabout a month before was said to have had the elementary characters which it pre-ringrrorm, which was followed by an erup- sented. But, had this same disease present-tion on the head and nates. When examined ! ed itself under more ullfavourable circum-the following were the appearances observ- stances ; had the vesicular or vesiculo-pus-ed:—Sealp thickly covered with an eruption tular character entirely disappeared, andand dried incrustation. In some parts vesi- the hair been matted together by the repeatedcles, in others ,Iustules, with an inflamed ; accumulation of the morbid secretion uf thebasis and a raised centre. Behind the ears, inflamed cutis, its real nature might not

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have been so easily determined. The pro-bability is, that it would have been classed

. among the porrigos, and suspicions enter-tained of its contagious nature. And hereI may with propriety introduce a fewobservations on the special and distinctivecharacters of the contagious forms of pus-tular affections of the scalp, in order to

simplify the means of discriminating be-tween them and other non-contagious pus-tular eruptions of the impetiginous kind.In the case which I have related no doubtcould be entertained, as I have alreadysaid, regarding its nature, not only onaccount of the presence of the vesicles, batfrom the forin of the pustule, which thereporter of the case has taken care to state,presented a raised centre. This circum-stance alone is sufficient to separate thenon-contagious from the contagious pustulareruptions of the scalp,-the form of thepustule, besides other equally importantcharacters, being the very reverse of the

former, viz., having a depressed centre.

But, in order to render this subject moreprecise and intelligible, let me state, in out-line onlv. the nustular affection!! of the

scalp. These are four in number : two ofthem have for their elementary characterwhat is called the favous pustule ; the twoothers the acbores pustule. Now, there canbe no doubt that the favous pustule is onesui generis, and essentially contagious, andincludes two forms of porrigo,-the porrigofavosa, and the porrigo scutulata, the trueringworm of authors, if not of the vulgar.The achores pustules, on the other hand, ifthey do not characterise a special diseaseof the scalp, are certainly not susceptibleof transmission by contagion, and hence animportant distinction between the diseasesto which they give rise and those of thefavous’character. The diseases of the scalp,however, arising in the achores pustule,have been included under the porrigos, andpresent two. varieties, the porrigo larvalisand the porrigo granulata. I am, however,disposed to think, with Biett, that theymight be separated from the porrigos, fromthe circumstance of their non-coctagiousnature, and also from their bearing a strongresemblance to impetigo or eczema impeti-ginodes, of which they are probably onlymodifications, owing to a differemce in theseat which they occupy. But, be this as itmay, it is obvious that our urcat object oughtto be to be able to distinguish the contagiouspustular eruptions from every other pustu-lar alrection of the scalp; and this may beaccomplished in by far the greater numberof cases either at first sight, or after watch-ing the progress of the disease for a few

days. The characters, then, by means olwhich we distinguish the two forms of con.tagious pustular diseases of the scalp,—theporrigo favosa and the porrigo scutulata,—are the following and, first, of those of por.

rigo favoa: the favons ptrsiate is formedby the deposition of a minute quantity ofpus, which concretes almost immediatelyinto a pale yellow or straw-coloured sub-stance, haviag a defined circular edge,hardly, if at all, rising above the surface ofthe skin, and surrounded by a slight blushof red. The successive effusion and con-cretion of the matter proceeds from thecentre towards the circumference, in whichdirection it accumulates, thereby raising thecircular edge of the crust, and giving to itthat cup-shaped form by which it is so readilyrecognised. The size of these concrete pus-tules varies from one to two lines,to half orthree-quarten of an inch in diameter. Theyare distinct at the commencement, but be-come confluent during their formation, andare sometimes confounded together into alarge, dry, brittle mass, resembling a mix-ture of sulphur and plaster. Even in this

state, however, of agglomeration, traces ofthe primitive character of the disease areperceptible, viz., numerous round or irregu-lar depressions, indicating the situation andnumber of the original favi.

In the second form, viz., the porrigo sru-tulata, the favous pustules, instead of beingdistinct, as in the former, are confluent fromthe commencement, and form patches, ofvarious extent, around the circumference ofwhich they are much more numerous thanat the centre. Patches of this kind may beseen on various parts of the scalp, but, how-ever mnch they may increase in extent, bythe accumulation of the concrete effusedmatter, and although, from this circumfer-ence the alveolar depressions may becomeeffaced, the projecting, defined, circularedges of the favi are always to be observedaround the circumference of the patches,and serve to point out the nature of theaffection. The concrete matter of the patchesresembles plaster, is of a dirty..grey colour,rather than a yellow tinge, as in the porrigofavosa. Such is a general outline of thephysical and distinctive characters of whatmay be regarded ns the true porrigos,-theporrigo favosa and scatulata,—and by meansof which % e are enabled to distinguish themfrom other pustular affections of the scalp

with which they are confounded, that is toBav. with impetigo, eczema impetigino-des, and still more so with the porrigolarvalis and porrtjro 1franulata. I have

already said that these two latter pustularaffections have not the favous but theachores pustule for the basis of their clas-si6catioa, and that it is extremely probablethat the achores pustule is merely a modi-fication of the pustule of impetigo, affectedby ite locality, and consntute.when seated inthe scalp. va’rieties of impetigo and eczemaimpetiginodes. The achres pustules, how-ever, which eotMtimte the porrigo larvalis

and granulata, are larger than those of theporrigo favosa and wutullts, at their com-

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mencement. They are situated superficially,instead of being sunk deep in the cutis, asis the case in the latter: they are, in fact,prominent, instead of being depressed; aresurrounded by an inflamed basis ; are scat-tered over the head or other parts of thebody; and instead of the puriform fluidconcreting when effused within a definedcircumscribed space, it is spread over the i

surrounding surface in the form of lami- nated, brittle incrustations, of a yellowish-green, yellowish-brown, or brown colour.The dry, irregular incrustations, independ-ent of the colour, of these two non-contagiousforms of porrigo, cannot be confounded withthe solid circular patches, with depressedcentres, of porrigo favosa aud scntulata,the only two pustular diseases from which,as I have already said, it is of importancethat they should be distinguished.We now come to the consideration of the

second case of eczema impetiginodes, whichis one of considerable interest, even in adiagnostic point of view, owing to theunusually obscure and complicated appear-ances which it presented. I shall first readyou the history of this case, taken from thecase-book, before offering you the explana.torv observations which it suggests.

History of Case.—John Smith, aet. 35, ad-mitted Decembt’r 4th, 1S38, formerly a groom, but for the last three years has beenempio cd as a gardener; he is of a sanguinetemperament, tall and muscular, married,and of regular habits; parents are living,and generally healthy ; his own health hasalways been remarkably good. Fourteen

years ago (before his marriage) he contractedgonorrhoea, and got well in about a fortnightby the use of internal remedies. He declareshe never had any venereal complaint since,nor, indeed, ever been in "harm’s way." Inthe summer, six years ago, he had an erup-tion of small pimples all over his body, onglans penis, and scrotum, as well as on otherparts. These were attended with very littleitching and died away spontaneously towardswinter; they have returned every summerabout June. The eruption was supposed,by his medical attendant, to be syphilitic,and the patient was salivated three timeswithin the twelve mouths, three years ago.At this time he states that he had a smallsweliing in the groin, which, however, soonsubsided after leechin; and rest. After thefirst salivation the eruption assumed anewform ; the pimples broke and discharged ayellow fiuid, which concreted into thickscabs. Similar pimples nuw began to appear on the scalp and face, being precedec

, by severe Leadachs. Each pimple brokeenlarged, joined with neighbouring ones

attd fermed large discharging surfaces, whichafterwards gradually heated at the centreon various parts oi the head, trunk, and extrernide-z. His throat became sore ; therwere large ulcers formed ia it, sad it coa

tinned in this state for two months. He be.came gradually worse and worse, and was,as stated, admitted, the 4th December.

Present Symptoms.—His face is nearlycovered with the eruption ; the patches areirregular in size, but generally assume acircular form; some parts are erythematous,covered with a furfuraceous desquamation,and around the margins of these patcheswhich have healed in various degrees iu thecentre, the still discharging eruption formsscabs and crusts of a yellow colour, by theconcreting of the matter furnished by thepustules. There are numerous patches onthe head, behind the ears, &c. &c. ; themargins of the patches are not raised, butthe skin around is red and shining ; the

eruption heals in the centre of the patches,and the parts, once the seat of the disease,do not again become affected. The affected

parts are hot, itch, and smart, and heat onlymakes them worse. There are several largepatches on the back. and on the front of thechest, one on the left scapula, and one onthe right breast, forming a complete ring.Another very large one is situated just be-low the knee, healed in the contre, the skinthere being of the natural colour, and an-other patch under the left thigh, four inchesin breadth. There are small red papulae,

containing fluid of a yellow colour, likeimpetiginous pustules, diffused over the bodyin various parts.

, The upper lip is much swollen, and pro-, truded ; the eyelids are thickened, there islippitudo and coryza; the sight is dim andiimp,,tired, and the eyeballs blood shot.I The skin is, at times, very hot and dry ;t

he is very much weakened by the disease ;

appetite is pretty good ; thirst; sleep bad ;, very little perspiration ; bowels regular ;

urine hisrh coloured. and rather increased in

quantity; tongue clean and natural.The history of this case suggests two in-

quiries : first, the nature of the eruption con-sidered in itself; and, secondly, its remotecause or origin. As to the eruption, it pre-sented far from common appearances, bothas regarded its general characters and thegreat extent of the surface which it affected ; in some of its characters it bore a faint re-semblance to psoriasis, particularly in theredness of the inflamed surfaces and the pre.sence of the furfuraceous desquamations, or,rather, thin whitish, transparent, laminatedscales, which covered a great part of tii-sesurfaces. It was, however, only in theserespects that it had any resemblance to

psoriasis, and that but a very imperfectone; for, in this disease, the squamae are

white and opaqne, and are not only accu-mulated into thick rugous masses, in chroniccases, such as that of our patient, but theinflamed cutis is thickened, hardened, and

fissured, which in this case was smooth andshining. Besides the somewhat scaly or

squamous character of the affection, which

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gave to it a resemblance to psoriasis, therewas also another circumstance calculated tolead astray, viz., the tendency of the largepatches to heal in the centre ; but this cir-cumstrance is observed in other and differentcutaneous diseases, and particularly in thatwith which this patient was affected.

Besides these negative characters of thedisease, there was one of a positive nature,which at once served to distinguish it from

pboriasis, viz., the incrustations, or scabs,which occupied principally the outer mar-gin or circumference of several of the patchesou different parts of the body. These wereof a yellowish or yelluwish-brown colour,obviously formed by the concretion of a

viscid secretion, such in fact, as is observedtooccnr in impetigoor eczema impetiginodes.No such kind of crust or viscid dischargeoccurs in psoriasis although in some casesof psoriaai6 inveterata, after an exacerba-tion of the inflammatory excitement, a slightdischarge may take place ; but even herethe resemblance to impetigo is extremelyremote in this as well as in many other cir-cumstances.Could there have been any doubt as to

the character of the disease as indicated bythe general appearances of the patches, andparticularly by that of the scabs, this wouldhave been removed by the presence of theimpetiginous pustules on several parts ofthe body.*

This form of impetigo is, as I have al-ready said, far from being common. It i3observed in persons of a lymphatic or scro-fulous constitution, and most frequently asa sequela of venereal infection, and possiblyin those on whose constitutions mercury ex-ercises an injurious influence. It is statedthat this patient had a gonorrhoea fifteenyears ago, which was removed in the courseof about a fortnight after the use of internalremedies, probably no mercury having beenemployed. Nine years after he had, insummer, what appeared to have been a pa.pular eruption over the whole body, includ.in the glans penis, and which disappearedspontaneously towards the winter, andwhich had returned every summer since.This eruption was supposed, by the medicalattendant of the patient, to be syphilitic,and three years ago he was salivated threetimes within the twelvemonths. Instead ofthis treatment having been of any serviceto the patient, the disease with which hewas afflicted became worse after the firstsalivation. Instead of a papular there nowappeared a pustular eruption, occupyingfirst the head and face, and accompanied bysevere beadach. It was at this time, also,that the throat became affected, and was theseat of ulceration for about two months.* A model in wax of a part of the body

a6ectsd with the disease was exhibited anddescribed.

From this period, also, the cutaneoos dis-ease increased in sererity until it had arriv-ed at that stage at which you saw it whenhe was admitted into this hospital.When I first saw this patient I did not

attach much importancp to the venereal ori.gin of his disease. ner was this to me a mat-ter of consequence, as the treatment em-ployed was that which has been found to be,in most cases of this nature, by far the mosteflications.You have heani titat he had fifteen years

ago only a gonorrhoua, although our evi-dence on this point is L) to means conclu-sive. However, were his statement correct,it would not be a solitary mstance of syphi-litic eruptions succrcdtug to gonorrhœaafter interval of many years. I have myselfwitnessed cases of this kind, ill which thecutaneous affection itself, eithei-,of a scaly,vesicular, pustular, or tubercular character,bore sufficient evidence of ita origin, andBiett. of the Hospital of St. Louis, of Paris,who has had the most extensive opportu-nities of investigating this subject, longsince informed me that the occurrence ofsyphilitic eruptions after gonorrhœa wasfar from being uncommon.

LN umerotis experiments, particularly thoseof M. Ricord, have, indeed, lately demon-strated, that the primary affection of themucous membrane is, in many cases of go-norrhoea. of the same nature as in chancre,the puriform discharge in these cases, whenintroduced into the cutis, being followed bythe formation of a true venereal sore, or

chancre, and its constitutional consequences.From a review of the history of this patient’scase, therefore, you will no doubt be dis-posed to consider the vesiculo-liusittlaraffection which he presented of syphiliticorigin. The sore throat, combined withsuccessive attacks of the cutaneous affec-tion, would, by most physicians, be consi-dered conclusive evidence in a case of thisnature.The treatment in this case was, in the

highest degree, successful ; how far the

cure will be permanent is yet a question.However, the further use of mercury in acase of this kind would have, I am certain,as it already had done, acted most injuri-ously. Indeed. I mav sav, that almost allthe bad cases of syphilis which I have seen,more especiaHy when the throat was exten-sively ulcernted, the nose destroyed, nodesof the bones, excruciating pains, &c., haye

occurred in persons who bad undergone reopeated courses of mercury, and without im-puting this to the deleterious operation ofthe merotry alone, it is no less an importantpractical fact that such consequences too

frequently follow the operation of this we-dicine iu coustitutions contaminated by

syphilis. The following was the treatment adopted

in this case -

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Dec. 4. Venesection, xii.; sol. of hyd. ofpotash,* 3ss., thrice a day; middle diet.

6. Blood buffed and cupped; skin lesshot.R Creosote, one drop ;

Water, vj.; a lotion for the affectedpart.

8. Lotion caused some smarting, and wasdecreased in strength; two ounces addi-tional of water. Increase solution to twoscruples.

11. Heat and itching less ; eruption paler.Sol. of hyd. of potass, 3i.

15. Improving rapidly. Sol. of hyd. ofpotass, 3 scruples.

18. Much less redness, heat, and smart-ing ; lotion diminished in strength from itscausing too much tingling. Sol. of hyd. ofpotass, four scruples.

22. Eruption still less red and tingling;natient feels much easier. but had an attackof headach and sickness, from having taken 3ss. of the solution, by mistake, more than was ordered.

25. Venesection vj. sol.of hyd. of potuss, 13iss.From this period up to the 10th of Ja-

nuary, the general health of the patient andthe cutaneous affection gradually and stea.dily improved.The use of the creosote lotion was conti-

nued, with some variation in its strength,and the solution of the hydriodate of potashgradually increased to 3v. A few daysafter the patient was allowed a more gene-rousdiet. On the 22nd he was nearly well,desirous of returning home; and on the 24thwas discharged cured, the only remains ofthe cutaneous disease consisting in a red-dish discolouration of the parts of the skinwhich were affected by the eruption.

SUBSTANCE OF

A CLINICAL LECTUREON

INJURIES OF THE HEAD,BY FREDERICK HALE THOMSON, ESQ.,

Assistant-Surgeon to the WestminsterHospital,

DELIVERED ON WEDNESDAY, APRIL 3RD, 1839.

PREVIOUSLY to entering into the matter ofhis lecture Mr. Thomson alluded to an errorwhich had crept (he supposed through theinadvertence of the reporter) into an abstractof some of his clinical observations publishedin No. 813 of THE LANCET. The reporterhad used the term drops, instead of graina, inspeaking of the doses of phosphoric acid.

* The solution of the hyd. of potass em-ployed in the hospital contains one drachmto the ounce of water.

The lecturer began by stating that theplan he should follow in his future clinicalprelections would be to select the most strik.ing surgical cases that might come underhis care, to analyse the etiology, the symp.toms, and the therapeutical progress of eachcase, and consider how far the facts elicitedtended to confirm, modifiy, or subvert the re-ceived principles of surgical pathology andtreatment. On this occasion he was inducedto select the subject of « injury of the head "for the theme of his observations, becausethe students had recently witnessed thetreatment of a most interesting case of frac-ture of the basis cranii, which illustratedsome of the most important points relatingto this class of injuries.The patient who was the subject of this

injury was J. T., aged 31, a respectabletradesman, who was brought into the West-minster Hospital on the 15th January, 1839,at 10 P.M., having fracture of the base of thecranium. He had been dining with somefriends in the city, and returning home ine-briated, ne arove ms gig against a iamp-post. He was pitched out, and struck thecrown of his head against the curb-stone.When brought into the institution there wasa severe contusion in the scalp over the pro-tuberance of the right parietal bone, andconsiderable haemorrhage from the right ear.The countenance was expressionless, butthe face was not livid. The breathing wasslightly stertorous. There was total loss ofboth motion and sensation in the right armand leg. The pupils of the eyes were ofequal size, but slightly dilated; they con-tracted sluggishly when the stimulus of

light was applied. He raised his left handfeebly to prevent his head being examined.The pulse of the left arm was slow andweak, whilst the right was rather full. Anhour after admission the pulse remained thesame, and the hemiplegia of the right sidecontinued. No irritation applied to the sur-face of that side could provoke motion inthe affected part or in any other. On tick-

ling the soles of the affected foot a develop-ment of automatic motion was observed ; thepatient drew up his leg to the body. Thesame irritation applied to the right bandproduced no corresponding motions in theparalysed arm. On tickling the soles of thefeet, the irides freely dilated, although thestimulus of light produced a contrary effect.Two hours after his receptiou in the wardvomiting occurred, and various matters, con-taining spirits and coffee, were thrown upfrom the stomach. After this the slightstertor in his breathing ceased. On expos-ing the surface to the air sensation of thearm and leg returned, and after a time mo-tion also. He folded his arms, turned onthe right side, and drew up the lower ex.tremities, as if experiencing the effects ofcold. The pulse was now 78, small and

weak, and after having his head shaved, he