worthy of remark, that they are sometimes so slight, as to excite no serious attention or alarm, except in an experienced observer. The history of the disease as detailed by Dr. C. as well preceding as during the attack, is too complete to require any comment, and the symptoms are too well known to make it necessary for us to give any abstract of them. Altogether it affords an excellent example of that patient and discriminating observation, which alone can lead to the satisfactory investigation of morbid phenomena.

In estimating the degree of danger Dr. C. observes, that convulsions are not, as is commonly believed, always a fatal symptom, though they invariably indicate great danger. He has never known a person recover, who in the beginning of the attack complained of sudden pain in the head. We have, however, very recently had occasion to witness a very severe attack in which this circumstance took place, and from which the patient appears to be slowly recovering, though it required the most vigorous and active treatment to arrest the progress of the disease.

On examining the condition of the brain after death from ароplexy, the first circumstance which excites attention is the large quantity of blood which flows first from the division of the scalp, and afterwards from the brain itself and its investing membranes. This arises from a very high degree of venous congestion. Hence an opinion has arisen, that it is this state of the circulating system which gives occasion to the disease. This, however, is not only hypothetical, but contrary to fact; for though the veins are every where turgid with blood, yet there is abundant evidence of a high degree of arterial action. From an attentive consideration of all the morbid appearances, Dr. C. regards the following as the most important and uniform.

First, the remains of an excited state of the minute arteries of the brain, and its membranes, this probably being the most important, as it is the most unvarying appearance; then the extravasation of blood, probably the consequence of the excited state of the vessels; the turgescence of the venous system; the enlargement of the ventricles, partial or general; and lastly, the serous effusion which is generally found in various parts of the brain, and which would seem to imply previous absorption of the brain.

Such are the general appearances within the cranium, and with these there is very commonly found a considerable degree of disorganization in the liver, of that kind which stands connected with the abuse of wine or spirits. Previous to offering his own views of the nature of these appearances Dr. C. makes some free remarks upon the opinions of several of the most eminent among our modern practical writers,-opinions, which, for the most part, are so many instances of that perverted fond

ness for hypothesis which has hitherto so greatly retarded the advancement of medical science. As the opinions, however, of men eminently qualified to form a judgement on such questions, they are undoubtedly intitled to respect; and Dr. C. is careful to oppose to them the result of his own attentive observation of the evidences of morbid action, or altered structure produced by the disease, and detected by examination after death.

It is the common opinion that the extravasation of blood which is generally found to have taken place, arises from the rupture of some single vessel. Dr. C. asserts that this is not the case. In none of his dissections has he observed any instance of the rupture of a considerable artery. By a very cautious examination of the seat of the extravasation, and washing away the blood from the cavity in which it is lodged, either by means of a syringe, or a camel's hair-pencil-(an operation of considerable delicacy and requiring several hours) the sides of the cavity will at last exhibit a great number of vessels not larger than a human hair, and terminating in small clots of blood, and these appearances may be often traced in distinct and unconnected parts of the same brain. The extravasation cannot therefore originate in the causes usually assigned for it, such as aneurism, or ossification, or erosion, but must be owing to some simultaneous action of the smaller arteries, which extends to the whole or a considerable part of the brain, and which these vessels, notwithstanding their strength, are unable to resist. To these views, deduced as they are, from the careful examination of a pretty considerable number of cases, it appears to us that no satisfactory objection can be made; nor can that author be charged with a premature or rash spirit of generalization, whose conclusions are drawn from so large and comprehensive a series of observations.

The preceding remarks relate to that species of apoplexy which is described by Nosologists, under the title of sanguineous. But there is another variety described by medical writers under the name of serous apoplexy, to which the succeeding section is devoted. This, when compared with the sanguineous, is a rare disease, and its nature appears to be involved in considerable obscurity. Scarcely any thing is known of its causes, and the testimony of very competent anatomists, all concur in representing the morbid appearances as inadequate to account for the cause of the patient's death: as they often amount merely to a slight serous effusion between the convolutions on the surface, or in the ventricles, leaving the countenance pale and free from distortion. It seems to us, indeed, to be a misapplication of the term to call the disease, apoplexy, as it cannot be said to have any single feature of that disease, except

perhaps the suddenness of its invasion, and its immediate destruction of life. Dr. C. remarks that he examined one of these cases with great care, ' and although there was evidence of death having been occasioned by a disease of the brain, yet there was scarce any resemblance between the diseased appearances, and those which are usually produced during sanguineous apoplexy.' He had not seen any of these persons until after death, and very properly hesitated in giving a name to the disease.

In discussing the treatment of apoplexy, Dr. C. recommends the free employment of venesection, with a degree of earnestness which proves that his own experience has impressed him strongly with its importance, and we are satisfied that he does not over-rate its value. He distinctly asserts it to be, in his opinion, not only the most effectual remedy, but superior to all others combined. And yet there have been men of considerable eminence in the profession, who have disapproved of bleeding on theoretical grounds, and have given the sanction of their authority in opposition to a practice which alone affords any chance of safety. Of this number was the amiable and benevolent Dr. Fothergill: but no opinions supported merely by theoretical reasoning can be placed in competition with that knowledge which anatomical examination has supplied us with. Dr. C. observes, with great propriety, that if the display of the brain destroyed by apoplexy, does not prove how indispensable venesection is, every other argument in favour of it must be accounted weak.' One argument urged against it, is the occurrence of palsy as the consequence of apopletic seizure, when bleeding has been employed to remove it: but this is futile, as it is well known that palsy often precedes an attack of apoplexy and even when it does not terminate in apoplexy it is sometimes marked by strong symptoms of inflammatory action: indeed, in some instances Dr. C says he has averted an attack of apoplexy by the free use of venesection in persons recently seized with palsy. A stronger ground appears to have been taken by those who have objected to it, from an apprehension that the attack might be of the serous kind. But in the first place these cases are rare; insomuch that out of more than fifty fatal cases Dr. C. thinks he has only met with one of this description, Secondly, in the present state of our knowledge, it does not appear that we have any certain diagnostic symptoms, to guide our treatment. To distinguish between these, if indeed it is possible, is a matter of extreme difficulty, as neither the age, sex, appearance, nor even the habits of the individual as to temperance, afford any certain criteria; for cases in which all these circumstances would have led to the idea of the disease

being serous apoplexy, the vessels of the brain have been found gorged with blood. It ought therefore to be laid down as a general rule, that every apoplectic patient should be bled largely, as soon as possible after the seizure.

To the active practice here recommended, the employment of emetics has been preferred by many practitioners. This mode of treatment was revived, and strongly recommended, by Dr. Fothergill, and rests at present very much on his authority. Dr. C. has examined it very fully, and as we think, very candidly; but his disapprobation of it is strong and decisive. When, indeed, a person is threatened only with an attack, from intoxication, or from the still more odious species of intemperance which Bacon somewhere calls the drunkenness of eating, the unloading of the stomach by the gentlest means, is not only safe, but will commonly afford the most prompt and sensible relief. But in a confirmed apoplexy, Dr. C. is clearly of opinion that no means of inducing vomiting can be employed without danger. With respect to cathartics, or the other expedients for unloading the stomach, no difference of opinion can be conceived to exist, and next to the lancet they are perhaps the most powerful means which we possess. Dr. C. disapproves of blistering on the scalp, especially in the early stage of the treatment, as the irritation, he supposes, must excite the arteries of the membranes of the brain into more powerful action. When the force of the attack is broken, blisters may be useful. The application of cold water and vinegar, or iced water to the head after it is shaved, is always to be enforced, and is commonly productive of considerable relief.

Dr. C.'s commentary upon the history of the disease, which he has introduced, including some valuable observations on its causes, is highly instructive. His remarks place the value of temperance in preserving health, in a strong point of view. The influence of irregularity, he thinks, is far more operative than that of temperament or conformation. In the majority of instances the disease might be postponed or averted by temperance alone; and from the general prevalence of more rational habits, it is certain that the disease is less frequent now than it was thirty or forty years ago, Dr. C. places the use of tobacco higher in the list of exciting causes, than is commonly done by practical writers-in which we most cordially agree with him. He remarks that many persons who have been carried off by apoplexy, have been subject to irregularity of pulse, and to incubus, with palpitation of the heart. The connection of the disease with affections of the loins and stomach is a frequent occurrence, and Dr. C, mentions the fact of a gentleman who had lived freely in the early part of his life having been thrice threatened with an attack, from which he was finally relieved VOL. X, 2 D

by the disuse of sugar and preserves (which he had used largely in his diet) after many other expedients, both medical and dieteic, had failed to afford relief. The observations of our author on this very important, but obscure part of pathology indicate habits of close attention, and are the more valuable as they are unalloyed by any admixture of hypothesis, while his reasonings are remarkably clear and satisfactory.

With regard to the comatose diseases, our knowledge has been for some time stationary. The observations of Dr. C. are therefore important, from their having a tendency to excite attention to an important class of morbid affections; but they are entitled to higher praise; for they are candid, ingenious, and discriminative. The subject, however, is singularly obscure, and Dr. C. advances no pretensions to a finished essay. He attributes, and we doubt not with propriety, the neglect which these affections have recently experienced, to their imperfect classification in the nosology of Cullen, and to the erroneous view given in the "First Lines" of that celebrated teacher, whose works have been the text books of by far the largest part of the practitioners of the present day. Hence, as Dr. C. observes, these diseases have scarcely been mentioned by any later English physician;' and the student who is desirous of information on the subject, must consult the writings of earlier authors.-Dr. Cheyne is disposed to consider lethargy as the genus, of which veternus, cataphora, and carus, are the species, or perhaps varieties. They appear to differ from each other only in degree.

A confirmed lethargy or cataphora resembles concussion in many of its symptoms, carus reminds us of that compression in which the brain labours under a large clot of blood; sensibility appears nearly exhausted.

Carus, in general (Dr. C. continues) is to be distinguised from apoplexy, not only by its peculiar symptoms, but as being the sequel of other comatose affections; as following lethargy. Indeed, it is by no means unusual to see carus after apoplexy itself; the patient, after a certain time becoming pale, with a slow depressed pulse, breathing softly, but totally inexcitable.

• When these affections appear in sequence, the milder gradually degenerating into the more severe, we may generally discover that, for a certain time, the patient had been complaining of flushing of the face, or throbbing of the temples, or some symptom of increased activity of the circulation in the head.'

Dr. C. thinks that lethargy and palsy have no necessary connection; but being diseases of the same period of life, they are sometimes combined, and perhaps the exciting causes of each are very much the same. A determination of blood towards the brain, and the daily abuse of stimuli are among the most frequent causes of lethargy; and the remark would equally