tons. PATHOLOGY OF GENERAL PARALYSIS. At the present moment his health he the ependyma of the ventricle, as the center considers perfect, but acknowledges that in or perhaps one of many centers of that dethe past he has had many sicknesses and instructive process which is indicated by the firmities. Matters of recent occurrence symptoms of general paralysis, which affects which have not had opportunities for repeti- all parts of the encephalon, and produces tion and so have not become organically these secondary pathological appearances registered and automatic, and that conse- that have previously been identified as the quently involve consciousness, are far more cause of the disorders of mobility and sensidependent upon mind than matters of earlier bility which follow. The progress of the date, which have been so frequently repeated morbid degeneration, from the point when as to acquire automaticity. The patient, the ventricles have become dilated, their therefore, while stating with accuracy events ependyma thickened-when their surface, and detailed accounts of the past, can give especially in the fourth ventricle, is covered but a very vague and confused account of with granulations, is probably upwards along the events of the last few days or weeks. the connection as well as involving all tissues, This defect in memory is consequently one and is gradual and insidious, and can only of the most noticeable symptoms in the early be traced by the more advanced alterations stage of the disease, and we observe it par in structure. (It is proper to state here that ticularly in persons of methodical habits. Dr. Boyd, the late physician and superinLeaving this interesting field of the psy- tendent of the Somerset County Lunatic chology of general paralysis, we proceed to Asylum in England, disputes Dr. Magnan's notice its pathology. claim to the priority in the discovery of the pathological changes in general paralysis, calling attention to his observations made about thirty years ago, in the second annual report of the Somerset County Asylum.) This interstitial irritation, however it is disseminated, is propagated by nuclear proliferation, and invades the white matter in common with the cortical substance and also the capillaries which are thickened, tortuous and massed together. The cells of the cortical portion are sometimes found infiltrated with granulations but preserving their form. This is found in the third stage of the disease. It is in the middle and inferior portions of the grey matter that the cells are observed to have brilliant nuclei tending toward colloid, while their normal aspect is preserved. The walls of the cell nearest the lesion are transformed into a shining, refractory, hyaline substance, the colloid infiltration having been propagated to both. The microscopic appearances, as well as the naked eye appearances, may appear first in the brain, and subsequently in the medulla, or they may appear first in the medulla and afterwards in the brain; and they may also appear simultaneously. If the brain is primarily attacked, the physical signs predominate or are exclusively manifested. If the medulla be the primary seat of the disease, muscular pain, tremor and ataxic symptoms, spreading gradually to the lips and tongue, disturbance of the internal viscera The pathology of general paralysis is very obscure, and invites especial attention at the hands of the profession. Dr. Magnan* a distinguished physiologist and psychologist, the superintendent of a Paris insane asylum, considers that the fundamental lesion of this disease is a general diffused interstitial encephalite, which involves accessory structural changes of various character. He regards the primary and most palpable form of the interstitial degeneration as colloid, where the transformed matter is presented under the aspect of a hyaline substance, semi-transparent, slightly refractory, and at certain points of a bluish tint. When existing in isolated masses of small size, it preserves the form and aspect of whatever cerebral elements it may have invaded. This product of inflammation which Dr. Magnan does not claim to be tubercular, is not of a fatty nature, because insoluble in ether or chloroform. It is not amyloid, because unaffected by tincture of iodine, or solutions of potassa and soda, and is dissolved in strong acetic acid. It is not organic, as there is no reaction with hydrochloric acid. Its solubility in hot water, especially when potassa or soda is added, is supposed to establish the possession of a peculiar chemical composition. In examining the cerebrum as the principal seat of paresis, Magnan claims priority in having determined *Recherches sur des centres nerveux, pathologie et physiologie pathologique, corresponding to the portions of the spinal pia mater are of considerable size, the walls column involved, precede alienation and in- of the capillaries incrusted with granulacrease the difficulty of diagnosis. Finally, tions, the surface of the pia mater presenting when the whole cerebro-spinal axis partici- scattered cell granules and molecules, and pates at once in the colloid degeneration, the extravasated blood globules. The grey subcharacteristic indications of paresis will stance is greatly developed with palpable appear simultaneously or in rapid succession. vascular aborisations, often in the form of a It is important for us to bear in mind that plexus. The calibre of the capillaries is the colloid degeneration upon which Magnan almost always contracted by the incrustation insists is far from being constant in paresis, of minute granules, or by cells deposited and we meet with it in other diseases re- chiefly at the bifurcations, which are of irmotely connected, or perhaps in no degree regular shapes, and break down and disconnected with paresis. For instance, the charge their contents. The nerve tubes are ependyma of the fourth ventricle has been malformed, their contents escape, and they found to be the seat of the same changes as present little more than a mass of debris. in paresis after muscular atrophy, chronic Rokitansky has detected three distinct pathoalcoholism, senile dementia, tetanus, and also logical appearances. 1st. Where a mass of after tubercular meningitis. I will now cite connective tissue embraces in its network the as concisely as possible the opinions of the nervous element, and in chronic cases is stiff, highest authorities relative to the pathology fibrous, and induces adhesion of the pia of the disease under question. Bayle desig- mater. 2d. The tubes are 2d. The tubes are varicose and nated the disease chronic arachnitis. Cal- broken, while the cells appear swollen. 3d. miel considered it as a diffuse chronic men- The presence of amyloid or colloid bodies. ingeal encephalite, and held that it was of Wedl's observations are as follows: That inflammatory origin. Baillarger observed contraction of the capillaries and small blood two sets of anatomical alterations, conges- vessels, in consequence of the cells upon their tion of the membranes and chronic hydro- walls, leads to obliteration, their conversion cephalus, with atrophy and softening of the into bands of connective tissue, and the conbrain. Brunet and Lanceraux speak of a sequent impairment of the nutrition of the neo-membrane, or a pachymeningitis, the part. Dr. Ertzbischoff attributes the hyformation of which they explain by the exu- peræmia of the cortical layers to the extreme dation of a parietal layer from its walls, development of the embryoplastic element which is insensibly organized, and which bears in the capillaries, which, by compressing the the marks of fatty degeneration. The rup- vessels without and within, diminishes and ture of these vessels leads to the occurrence ultimately destroys the cavity. This stasis of arachnoid cysts. Erleumayer explains the necessitates granulations and adhesion. The atrophy which has been noticed, by the suc- majority of the German pathologists localize cessive and repeated effusions of serum, the the disease in changes of the walls of the nervous elements being replaced by an vessels, and in the development of the conamorphous substance. Frerichs considers nective tissue. Meschede sees the essential the induration of the grey matter as con- characteristics of paresis in the degeneration necting the pathological condition condition with of cerebral cells, especially those of the sclerosis. The alterations in the white mat- cortical substance which he depicts as of ter consist of hardening or softening, increase abnormal shape and filled and surrounded of fluid of the ventricles, and thinning of with fatty and pigmentary granulations. their parietes, which resemble indurated Lockhart Clarke speaks of the conversion of ependyma. M. Luys, who by the way is a the cells of the convolutions into pigmentary able French investigator, believes that bodies, irregularly shaped and about to break in the softening of the cortical substance of up. Contemporaneously with this change, the the cerebellum may be discovered the source spinal marrow, especially in chronic cases, is of general paralysis, but Magnan asserts that softened to the consistency of cream, or there this conviction of M. Luys is founded on may be a granular degeneration in its grey exceptional cases. M. Luys gives as the matter or its surroundings. Westphal has result of his microscopic investigations the discovered in some cases granulations in the following results, viz.: The vessels of the posterior columns of the cord which did not very extend higher than the peduncles of the too large for the mouth or too heavy for use, cerebrum, so that the alteration could not be very flabby and easily indented by the teeth; regarded as secondary or as proceeding from a peculiar dragging of one of the feet or the pathological condition of the convolu- legs, and added to these symptoms will be tions. found a heavy, dull expression of counten The course of general paralysis may very ance, and an unusual appearance of the eyes, properly be divided into four stages: and almost invariably an unequal contraction of the pupils. It requires careful observation to detect these symptoms in the 1st. That of delirium, with or without slight physical lesions. 2d. That of defective co-ordination of early stages, and careful treatment may removement, exaggerated sentiments, altera-lieve them temporarily, but although we may tions in the secretions, with continued de- retard the issue of the disease by careful lirium. 3d. That of special dementia, with greater stupidity and degradation than in other forms; the control of muscles diminished; habits dirty. watching and skillful treatment, it inevit ably advances insidiously to paralysis of the tongue and limbs and progressive enfeeblement of the mind. In the last stage, which sometimes lasts for years, emaciation succeeds obesity. Sometimes there is intense 4th. Perception of impressions by external restlessness, but generally we find lethargy senses abolished; insensibility to pain; ex- of body as well as of mind, this lethargy tinction of functions of relation and organic being disturbed by twitchings, or epileptilife; disturbance in circulation; complete form convulsions. adynamic ataxy and marasmus. Optimism, and ambitious ideas, as I remarked in the first part of this paper, con stitute the essential mental characteristics. Previous to the establishment of complete delirium or delusions, there may be traced deviations from healthy mentalisation, which, though faint or latent, should be accepted as prodromata. There is no doubt that the gradual evolution of physical and psychical symptoms corresponds intimately with structural alterations in the nervous centres. Owing to having employed galvanization of the cervical-sympathetic with temporary beneficial results in some cases of general paralysis, the following question has presented itself to the author: Whether some of the These often terminate life, but the most frequent causes of death are sheer exhaustion and tubercular disease. With regard to the condition of the retina, we find the nerve changes generally proportionate to the contraction and dilatation of responding to the early or the hyperæmic the pupils the contraction of the pupil corstage, and the dilatation of the pupil to the With regard to the temperature, I have white atrophic condition of the optic disc. that there is always a higher temperature in always noticed, as an unvarying symptom, less than one degree, and in excited cases the evening than in the morning. Seldom sometimes a difference of two degrees, and we may, by the thermometer, discover the principal changes occurring in paresis may it satisfactorily by any other means. progress of the disease when we cannot do In not have their origin in a congestion origin- sleepless and destructive cases the temperaating in the ganglia of the sympathetic, ture is higher than it is in quiet cases. transmitted along the spinal cord, ultimately involving every tissue within the cranium, may consider the average duration of geninvolving every tissue within the cranium, eral paralysis as about thirteen months, and and eventuating simultaneously in the degeneration of blood vessels, cells and ner- very few patients live more than three years after the development of well-marked sympvous tubes and the mental and motor perversions which distinguish in so marked a manner general paralysis from all other disIn closing this little monograph on general eases of the same class? The diagnostic paralysis there are three questions which are symptoms of general paralysis, aside from very interesting to psychologists and to the exalted notions, are difficulty in articula- which I would invite their attention: tion, with a trembling of the tongue when 1st. Are the psychical excitement, exaltathe attempt is made to protrude it beyond tion and delusions of general paralysis to be the teeth, often a turning to one side and a regarded as the factors or promotors of the general inabilty to use it freely, as if it were physical degeneration? toms. We 2d. Are we entitled to hold (in remis- pital and examined by Drs. G. A. Foster sions in general paralysis) that the physical and M. K. Ross, who recognized a displacedegeneration was stayed or disappeared dur- ment of the head of the femur upon the dorsum ing the cessation of mental disease, giving ilii. By manipulation, they detected a displace to healthy structure? tinct crepitus, but were unable to determine 3d. Are we entitled to hold in general positively the exact nature of the fracture. paralysis that the resumption of apparently Reduction was readily accomplished. The healthy action was compatible and co-exist- accident occurred at 4 P. M., and the patient ent with persistent structural degeneration? died early next morning, evidently as the result of shock, due to the combination of Fracture of the Posterior Lip of the Left injuries received. BY H. O. WALKER, M. D., Lecturer on Anatomy and Genito-Urinary Diseases in the I. Detroit Medical College. At the inquest the coroner directed me to make a post mortem examination, and I will here only make mention of that part pertaining to the injury at the hip-joint. InS., aged 78; a street laborer, in at- spection revealed the head of the femur still tempting to avoid an approaching in position, but on slight manipulation of street-car, was knocked down by one of the the leg by flexing and adducting the thigh, horses. He fell upon his hands and knees, the head of the femur readily slipped out with his back to the car. In this position, of place, accompanied with a marked and the platform of the car struck upon the lower distinct crepitus. portion of his back, and, as the sequelæ will show, the thighs must have been at right angles with the pelvis, or nearly so, when he received the blow. The injuries received were a severe scalp wound, a compound comminuted fracture of the right forearm, with a number of contusions on different parts of the body. Aside from these, there was an injury to the left hip. He was taken to Harper Hos Further there was inversion of the foot, marked adduction and flexion of the thigh, with the head of the bone distinctly felt high up on the dorsum ilii, and shortening about three inches. After several attempts it was found that reduction could best be effected by flexing, extending, adducting and straightening the thigh. On exposing the femur and contiguous parts, it was observed that the head of the *A paper read before the Detroit Academy of Medi-bone had been forced upwards between the cine, May 27, 1879. wings of the ilio-femoral ligament, extending nearly up to brim of pelvis, midway between the anterior and posterior superior spinous processes. The ligamentum teres and the greater part of the posterior half of the capsular ligament were torn away, leaving a part of the anterior portion, together with the ilio-femoral or Y ligament. The muscles of the lower gluteal region at the femoral attachment were more or less ruptured. The fracture of the rim of the acetabulum can be better appreciated by the specimen which I removed, and I herewith present for your inspection. The fragments, which you see, were all detached and picked out from the cavity that had been made by the head of the femur. You will notice that a greater part of the posterior lip of ally occasioned by a heavy weight striking the acetabulum is torn away, making an the back, the thigh being flexed at right opening through which the head of the bone angles, or nearly so, with the pelvis, and poscould readily escape, leaving a little less sibly with a slight adduction or abduction. than a third of the depth of the cotyloid cavity intact as a support to the head of the bone posteriorly. An extensive fracture of the rim of the acetabulum is of rare occurrence, and the positive evidence of such a fracture a still greater rarity. was Where the diagnosis is satisfactorily made out, and when the head will not remain in position, Hamilton recommends the same treatment as in fractures of the femur, without the side splints, using extension and counter extension. It has occurred to me to recommend the application of a plaster of Paris bandage, extending from the ankle to umbilicus, and the placing the patient as soon as possible on crutches, and the wearing of an elevated shoe upon the well foot, so that extension would then take place by the weight of the leg. In looking over numerous works on surgery I have been able to find but very little pertaining to this fracture. A careful examination of the London Lancet, since 1823 up to the present time, was rewarded by finding mention of only two cases, and one of these, reported by Brodie in 1833, a supposed case, owing to an inability to keep the head of the femur in place. The other, reported by Chas. H. Moore, in 1851, was only discovered many years after the occurrence of the injury; the patient having died from pneumonia, an examination of the hip revealed a meet with inability to maintain reduction. stellar fracture of the acetabulum, with a portion of the rim detached allowing the femur to slip upon the dorsum forming a false joint. The standard works upon surgery give the subject only passing notice, to the effect that this fracture does occur, and that great difficulty is experienced in keeping the head of the femur in place. I think it probable that in many dislocations of the thigh upon the dorsum ilii, there is a strong liability to a greater or lesser detachment of the rim of the acetabulum— but that it does not interfere with maintainance of the reduction, and that it is only in an extensive fracture of this kind that we 177 Griswold street, Detroit. Observations, Chiefly Clinical, on Anomalous and Obstinate Fevers. BY F. GUNDRUM, M. D., IONIA, MICH. (Continued from the May number of THE LANCET.) In our first series of cases we had as a result, peculiar to all states where there is an increase of retrograde change, especially Dr. Frank Hamilton, in his work upon in pyrexial states over that of structural re"Fractures and Dislocations," devotes but a formation, a more or less body waste, which little over two pages to its history, symptoms, may ultimately, in and of itself, become diagnosis and treatment. He states that dangerous to the existence of life. There fractures of the rim of the acetabulum have were no particular tissues or organs attacked, been discovered in dissections, and that the it was a matter only of a morbid material, failure to reduce and maintain a dislocation producing increase of the normal consumpof the femur on the dorsum has been attrib-tion and a diminution or limitation of the uted "not always with sufficient reason, to material by which the tissues rebuild themthis fracture." The symptoms of this fracture point to a dislocation, with a difficulty, if not an impossibility, of retaining the head of the femur in place. The crepitus, when recognizable, is generally manifest at the commencement of manipulation, and will distinguish it from a fracture of the neck in connection with displacement, as in the latter the crepitus is not felt until the broken surfaces of the bone, are brought in apposition. selves. In these, and similar cases, the fire that is raging in the body must have something to consume, and could we do here what the fireman can do with his engine, we should be all right, but our position is entirely the opposite. The appetite is very much reduced or nil, salivary secretions and buccal digestion, which are so important, are almost or quite nothing when compared with the normal condition. The stomach is more or less irritable, rebels The production of this accident is gener- against food or takes it in limited quantities, |