Still, with this slender hope, the antisyphilitic treatment has been displaced by tonic and supporting measures, apparently with some advantage. Occasional free watery purgation relieves the headache somewhat, and by the use of antineuralgics and morphine much of the otherwise inevitable suffering is avoided. In such a case it would be cruel to withhold morphine on account of the danger of the morphine habit or on account of the slightly increased danger of a rapidly fatal termination.

But before we resign ourselves to a merely palliative treatment we must earnestly consider whether it is possible to cure by surgical means. Of all intra-cranial tumors, about one in twenty is so situated and of such a nature that its complete removal and the subsequent restoration of the patient to health are possible. The cerebellum is a very unfavorable region for operation. A growth in it can be reached only through the inferior surface, and it is not known how much damage the organ can sustain and the patient live. All manipulations in this region are exceedingly dangerous, on account of the close proximity of the pneumogastric nerves and of the vital centres in the pons and medulla. Starr tabulates sixteen cases of operation for cerebellar tumor: in nine the tumor was not found; in two it was found, but could not be removed; in three it was removed, but the patient died; in two cases the tumor was removed and the patient recovered, at least for a time. Now, if our patient had one chance in eight of a successful removal of the tumor, there could be no question of the propriety of operation; but he has no such chance. The staggering and deafness indicate that the middle lobe is involved, probably in its anterior part: so we have the most unfavorable situation for an operation. Moreover, a tubercular tumor is a very unfavorable kind for removal, on account of the danger of there being more than one growth, and of the difficulty of removing completely even a single one. Von Bergmann rather advises against attempting to remove tubercular tumors of the brain in any situation; and, while in this he is probably over-cautious, there can be no doubt that the successful removal of a tubercular tumor from the middle and anterior part of the cerebellum is entirely beyond any reasonable hope.

We must be content, then, merely to palliate this patient's suffering, while waiting for death to end it. Nevertheless, this minute study of his case has not been useless, for the application of the same principles to the next case of intra-cranial tumor may lead to a cure by means of mercury and potassium iodide, or perhaps to a successful operation.

CEREBRAL MENINGITIS; LEAD-POISONING;

ALCOHOLISM.

CLINICAL LECTURE DELIVERED AT THE COOK COUNTY HOSPITAL, CHICAGO.

BY DANIEL R. BROWER, M.D.,

Professor of Mental Diseases, Materia Medica, and Therapeutics, Rush Medical College; Professor of Diseases of the Nervous System, Woman's Medical College; Professor of Diseases of the Nervous System, Post-Graduate School; etc.

LADIES AND GENTLEMEN,-Those of the class who saw the infant with tubercular meningitis will recognize the decubitus of this patient as the same. You notice the head is thrown backward. This has been the position of the patient ever since he came into the hospital. We can always get a great deal of information by simple observation. I am inclined to think the older practitioners in medicine, in having to rely more upon it, were better observers than we of to-day, with our many instrumental aids to rapid and accurate diagnosis. While these aids are very valuable, we are apt to place too much dependence upon them. Learn to study that which may be seen without the use of any but the ordinary means of observation you all possess. The physiognomy of the patient, the position in bed, the number and rhythm of the respirations, and the many other important points accessible to the eye should not be ignored for the more accurate and invaluable evidence furnished by the thermometer, the stethoscope, the aspirator, and the instruments of percussion.

History.-Patient admitted to hospital, February 23; no previous history, except that he had been sick for a week before admission; was delirious; complained of intense pain in the head and along the spine in the cervical region. Examination of the heart, abdomen, and lungs negative; pupils dilated; bowels constipated.

Mark the three symptoms which in this case are especially worthy of your attention,-headache, vomiting, and constipation. These are the three leading symptoms of meningitis. The pain in the head was excruciating. When I saw this man last Monday, the 22d, he had

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his hands to his head and was tossing back and forth in bed incessantly. This is the pain of meningitis; and with it he had vomiting, constipation, and delirium. To-day, the 26th, he is very quiet, and just what this quietude means is not so certain. These cases of meningitis may very often deceive us. We shall find our patient delirious, restless, full of pains, hyperesthetic, as this man was the other day; when touched almost anywhere, he showed evidence of pain. To-day he is sleeping and seemingly quiet. The only thing peculiar about the sleep is that his eyes are not closed. When we raise the lid, we find the pupil not far from the normal condition, neither especially contracted nor dilated. This quietude may be the result of his treatment. He has been taking potassium bromide and deodorized tincture of opium, supplemented by hypodermic injections of morphine. The indications. for treatment during the first stage of meningitis are to quiet the patient,—to calm the nervous system; for this purpose we give the bromides and opium in some form. The movements and feelings of the patient should guide their use. I think these remedies should be given in sufficient doses to produce quietude. This condition which we find to-day may be the result of the treatment, and I hope it is, but we are often deceived in such a case. At one visit the patient may be found in a state of delirium; at the next he may be perfectly quiet, as this man is. Such quietude often means the passage from irritation to a state of pressure, when congestion gives place to exudation. Is this the coming on of the second stage of meningitis, or not? Has the intense congestion that has been prevailing in this patient's brain for so many days at length resulted in exudation? I am free to confess I do not at present know; to-morrow, probably, I shall be able to tell. The other day the pulse was strong and bounding, now it is soft and easily compressible. Then it required considerable pressure to obliterate it, now it takes but little. This may mean improvement of the patient, or it may indicate a more serious condition in the increase of pressure. The patient having reached this quiet stage, hypnotics and analgesics, no longer indicated, should give place to those remedies adapted to promote absorption. The patient has had an ice-cap on his head from the time of entrance, and counter-irritation along the spine. The former, having fulfilled its purpose, should be removed, and the sedative remedies should be gradually withdrawn, to be replaced by the iodides, preferably potassium iodide, in alterative doses.

These cases of meningitis are always very serious, and the promise of recovery is doubtful; many of them get up from their beds and go about their business, but retain as a legacy some intracranial disturb

ance in the way of headaches, or in the shape of paresis. It is a most remarkable thing for one of these patients to make a full and complete recovery, and the prognosis as to recovery of any sort in meningitis is bad. It would be interesting to find out what is the cause of this disease. In the case of the little child you saw the other day, I expressed the opinion, which the post-mortem verified, that it was tubercular meningitis. Is this case one of tubercular meningitis? I think not, because of the suddenness of its onset and the violence of its symptoms. Furthermore, tubercular meningitis is not likely to occur at this time of life, this man being thirty years of age. What, then, is the cause? The man comes into the hospital without any history at all. We do not know whether or not he received an injury to the head, giving rise to an inflammation of the dura mater, making it in that case a pachymeningitis. There is no evidence of suppuration of the ear, nor is there any suppurative inflammation about the nose or eyes, which might lead one to suppose that it came from these not uncommon sources of meningitis. The affection comes on very often simply from exposure to cold; it is sometimes the result of an excessive use of alcohol, and sometimes the result of overwork; too much brain-work produces congestion of the organ, and meningitis is but a step farther in the same pathological direction. Syphilis is another cause. But what produced this man's disease we do not know; it is a case of simple non-tubercular meningitis. It looks like an example of the ordinary type, where the inflammation usually begins in the pia mater, but soon extends to the arachnoid, to the dura mater, and to the brain itself. When a case has progressed as far as this one has, you may reasonably suppose that the three membranes enveloping the brain participate in the inflammatory process, as does the brain itself, and at this stage you can safely call it meningo-encephalitis,-inflammation of both meninges and brain.

CASE II. We have here another interesting but not an uncommon case of nervous trouble. This is one of the great class of

neuroses.

History.-Family history, none. Patient, a man forty years old; drinks, and uses tobacco; was admitted to the hospital seven or eight months ago for the same trouble. Present affection began three weeks ago. Patient is well nourished, has a bluish line along the margin of the gums, and sordes in the mouth, has pain and slight tenderness over the abdomen, complains of weakness in the lower limbs, and is unable to extend the hands.

This man has been a painter for twenty years, and for nineteen years

he had no disturbance of the nervous system; then he was seized with this colic, and shortly afterwards there came on the wrist-drop, from paralysis of the extensor muscles of the wrist. You see he has not yet recovered the use of these muscles.

Lead gets into the system by several methods: I think its entrance is accounted for in the case of painters by their own carelessness. They get their hands all smeared over with the lead, and then are not careful enough in cleansing them before they eat; consequently, a good bit of the metal, doubtless, gets into the system by the stomach. Of course these men are continually exposed to minute particles of lead floating about in the atmosphere of the paint-shops and rooms where they are at work. Slight wounds, as bruises or cuts upon the hands, also afford entrance to the subcutaneous tissues, and, finally, to the general circulation. But I think the great majority of painters get lead into their system with their food. Some of these cases of lead-poisoning will be very perplexing to you. I remember being sent for, a few years ago, to see a gentleman of this city, a gentleman of leisure, with nothing to bring him in contact, in any ordinary way, with lead. He had painter's colic and wrist-drop, and for some time that case was a riddle to me. Finally, upon one occasion I got a good look at his hair, which gave me a clue to the mystery. He dyed his hair with a preparation of lead, and in that way had become poisoned. I have seen several ladies who were thus affected from the use of cosmetics. Some of the cosmetics that are most enduring, and do not come off with ordinary perspiration, consist largely of lead, and now and then you will find, among your fashionable female patients, cases of lead colic and wristdrop which owe their origin to these preparations.

The chief indication in the treatment of lead-poisoning is to promote elimination. The lead is very largely excreted by the kidneys and bowels, and by the skin to a slight extent. Elimination is promoted in these cases by the administration of Epsom salt, or some equally efficient saline laxative; magnesium bisulphate is esteemed one of the best of this class. In addition, potassium iodide is the one remedy indicated par excellence. The metal is taken up and carried out of the system by the influence of the iodide upon the absorbents. You can often verify your diagnosis by examining the urine. There is only one precaution to use in these cases of chronic lead-poisoning. Do not attempt too rapid elimination. I have once or twice seen bad results follow in the way of cerebral disturbance, intense pain in the head, and some delirium, from a too rapid letting loose of the lead in the system. If you give potassium iodide too freely, and endeavor too