Special Senses.-Smell normal, taste normal and equal on both sides of the tongue, also in front and behind, and no anesthesia or analgesia detected. Hears watch 8 in. R., in. L. Sight presbyopic, fields not contracted (rough test). Discs, R. normal, L. small hemorrhagic patch temporal side, probably traumatic.

Cranial Nerves (III, IV, VI).—Pupils are equal and react normal to both light and accommodation. Slight lack of fixation upon extreme lateral deviation both to R. and L., none upward or downward. No diplopia or ptosis.

V.-Sensory portion normal, power equal in motor, but mouth is not opened to full capacity.

VII.-Upon forced contraction upper face, slight tremor. R. lower not acting quite so free as L., especially lips.

IX. Palate acts mesially on phonation, and normal upon reflex stimulation.

X.-Voice very indistinct, a slurring of the words, especially the labials, rather thick in character. Difficulty in swallowing solids, both the first and second portion of the act of deglutition being impaired.

(Dr. Bryant kindly reports that vocal cords move well and normal.) XII. Tongue thinned at edges and crossed from side to side by well marked irregular furrows, also grooves from before back, L. half a little more marked than R, can be protruded slightly past teeth, but only on extreme effort. Power to move from side to side much reduced, general range much limited. Tremor marked. Tongue feels larger than normal. Sensory system, subjective, no pain or numbness in any area. Objective, no analgesia or anesthesia, and normal to thermal tests, throughout.

Motor system, neck muscles well developed and good range and power. Some atrophy of deltoids supra and infra spinatii, L. more than R., the same condition prevails to some extent with the pectorals. Arm and forearm muscles good, and about equal in power and range, thenar and hypothenar eminences and introssii of L. wasted and weakened, R. less. Power L. hand less than normal. Fibrillary tremor to be seen in shoulder muscles named at times. Lower extremities, power and range good; no wasting noted, no tremor. No inco-ordination; finger nose test. No Romberg signs detected.

Reflexes.-Deep. Jaw plus.
Supinator.
Biceps..

Triceps.

K. J...

Ankle J.

Ankle C

CASE No. II.-A. McD., female, widow, age 65; was admitted to the National Hospital, London, November 22, 1900, and died April 19, 1901. Complaint, paralysis, arm and leg; duration fifteen months.

Family history is nil so far as this disease is concerned, and as to family diseases there is no paralysis, fits, insanity or consumption to be found; one son had rheumatism several times.

Personal History.-Patient never had any illness, always led an active life, temperate in habits; no evidence of syphilis and no cause known for present illness.

History of Illness. -About fifteen months ago in bed a few days with influenza. and when able to be about noted that she dragged right leg. Two to three months later noticed the right arm becoming weak, soon after same trouble appeared in left leg and last left arm, all members becoming steadily weaker. Five months ago speech became affected, and she had some pain upon micturition, but no incontinence. Sight quite good and no mental changes noted. Has been confined to bed past four months, since which time she has been unable to walk, and cannot now stand, and the head drops. Has had some pain in right arm, none in any other region. No numbness, no sudden weakness; wasting of hands seemed to proceed weakness.

On Admission.-Dark complected, gray haired woman, much emaciated and looks very ill; mentally she seems intelligent, but is emotional and weeps readily; she does not show the smiling vacuous flacidity of usual bulbar palsy.

Special Senses.-Vision good, fields normal, also optic discs, hearing, smell and taste.

Cranial Nerves.-Palpebral fissures are equal, pupils small right greater than left, but react normal. No strabismus, ptosis or nystagmus. Motor portion of fifth feeble, but equal, sensory portion and seventh normal; tongue small and pointed protruded feebly just to edge of teeth; cannot be thrust into either cheek, and upon such effort emerges at angle of mouth. Lips very feeble. Palate moves mesially, but slightly, upon phonation, also reacts upon stimulation; the articulation is almost indistinguishable and ends in a sort of muffled rumbling sound, vowel sounds fairly good; seems unable to harden floor of mouth, and much difficulty in swallowing, the principal trouble being to get the food to the back part of the mouth, after which it is swallowed well. Larynx moves up well upon deglutition.

Motor System.-Much general wasting, no electrical reaction of small muscles of hands. All movements of fingers and hands nil, very slight at elbows and shoulders, fingers extended, thumbs against meta carpus. Forearm muscles react to faradism, small current; rigidity elbows and shoulders and effort to move them produces pain. Lower extremities much general wasting, no complete loss of power, but very feeble everywhere, slight rigidity of all joints, legs are extended. Neck muscles are small and feeble, cannot lift head from pillow. Back and abdominal muscles feeble and in a condition of hypertonus.

Respiration mainly thoracic and doubtful if diaphragm moves at all; no protrusion of abdominal walls in breathing due to rigidity. Fibrillary tremor at times in forearm muscles both sides; no place else.

Sensory. No objection changes.

Reflexes. Jaw present, no clonus, elbow and wrists present and equal. K. J. plus; double ankle clonus; plantars both extensor and brisk. Abdominal not obtained.

able.

Trophic Moist boiled condition palms and soles, sweats consider

Sphincters. No incontinence, but severe cystitis.

Heart feeble, but no disease; pulse soft, small and rapid, but regular, vessels thickened.

Note March 29.-Temporal muscles very feeble, mouth can only be opened to a limited extent, and there is probably contraction of the masseters; fingers can be inserted between teeth and she allowed to bite on it without producing pain.

Note April 19.-Night of 17th the patient developed bronchitis, and breathing became obstructed, as diaphragm is paralyzed. She improved somewhat later in the day; this morning became suddenly worse, face blue and quite unconscious, breathing steadily worse, then gasping in character, and she died in a few hours.

CASE No. III.-W. T., male, age, 41; English; tailor; was admitted to National Hospital, London, May 1901; died September 3, 1901.

Family History nil so far as diseases are concerned, having a bearing on the case.

Social Habits.-Used alcoholic drinks in moderation, smoked some tobacco, good surroundings.

Previous History.-Good; nothing bearing on the case.

Present Illness. -December, 1900, he first noticed that the end joint of the left thumb was weak, soon after he found the ball of the same thumb getting small. January, 1901, he took a long walk, and he found that the legs became weak and that they never seemed to recover. Three weeks ago he noticed that the right arm and hand became quite weak; they gradually became worse, in fact he seemed to become gradually worse all the time.

On Admission.-Is a moderately well developed, light complexioned male; is fat and flabby, and does not appear upon first sight as though he should be weak. Expression is hopeful and bright. Sleeps well, and speech is natural. Mental condition shows fair intelligence and good attention, memory is good and is not emotional.

Special senses and cranial nerves are all normal.

Sensory system, subjectively, he says at times he feels as if there was a numbness over the weakened extremities, objectively, he shows no alterations to touch, pain on thermal tests.

Motor system, because of the subcutaneous adipose tissue at first glance. one would not think there was much wasting, but upon closer inspection one observes the thenar eminences, the interossii of both hands are almost

gone, the forearin much weakened, the biceps pectoral, spinatii, deltoids are very weak; trapezius and rhomboids good abdominal muscles, are very weak, but neck and jaw good; both legs are much wasted so far as muscles are concerned, but in all these changes the left is greater than the right.

Reflexes. Abdominal and cremasteric present. Plantars present, jaw present. Biceps, triceps and supinator all minus. K. J. brisk ankle J. present.

Sphincters, bladder normal, but bowels sluggish.

Other organs all nominal. Gait, feet apart, feeble and has pronounced pes. cavis.

Note July. Does not seem to be improving, and gradually is becoming weaker and weaker. Died September 12, because of the involvement of centers of respiration and others in medulla.

Treatment in both these later cases strychnia, hypodermatically, was used together with massage and electricity, also such other general treatment as the necessities of the case seemed to warrant.

Case No. I represents the unusual outset of the malady, but nevertheless a type that at times is found in which the lower efferent neuron of the bulb is first involved.

Case No. II illustrates the more usual conditon, the involvement of both central and peripheral efferent neurons, and later the bulb manifestations being presented.

Case No. III illustrates more nearly the involvement only of the peripheral efferent neuron, but slightly of the central, and the bulbar symptoms coming only at the final termination of the case.

Etiology. The etiological factor is often obscure, and probably no one element enters into the cause of the disease in all cases, it depends upon a number of factors often, principal among which may be mentioned, sex, age, exposure, mental distress, trauma, over-exertion, a neurotic inheritance, and in some cases syphilis, but the last mentioned element does not occur with sufficient frequency to be counted scarcely more than a coincident.

Diagnosis. As to the question of diagnosis it is as a general thing not difficult, and only in the very early stage is any trouble liable to arise. Neuritis of the multiple type may be distinguished by noting that one has to deal with a nerve trunk lesion, and not a root lesion; again one finds sensory disturbances, as numbness, pain and often hyperesthesia and varions paraesthesias. If it be plumbism one notes the peculiar affection of the musculo-spiral branches and the lead line, and a history of the infection. In circumscribed pachymeningitis, one may have wasting, but there will be found also pronounced disturbances, and often evidences of

an irritative lesion, as spasm and rigidity with the pain. As to a diagnosis from the myopathies the following points should always be taken into. consideration, age, evidence of pseudo-hypertrophy, and careful inquiry into the family history for similar cases and with due consideration of these points errors are not liable to occur. Hematomyelia may possibly simulate the disease under consideration, but note carefully the onset and evidence of trauma, and subsequent history, often also there is a history of sensory disturbance and localized tenderness as well as of a secondary myelitis. If it be secondary hemorrhage one is dealing with, there will be a history of prodromal symptoms. It would seem from almost all other diseases of the cord with proper care and a careful history, a mistake in diagnosis should not occur.

DISCUSSION.

Dr. Barstow.-Dr. Coulter's paper is one of far too much importance to pass without thorough discussion. The lesson to be had from the paper is that we should be more careful in our diagnosis, because the only hope in these cases is that they shall have the very best care in the early stages. Dr. Bridges made a remark in the discussion of one of the papers read before the Omaha Medical Society which impressed me very strongly. He emphasized the idea that we do not examine our patients with sufficient care; that any of us can recognize the common or ordinary things with which we meet but that we miss many things which are out of the ordinary by reason of a lack of care in our examinations. When we meet with any unusual condition which we are inadequate to understand, we should at once refer that patient to the man whose experience makes him competent to deal with them.

Dr. Mary Strong. With regard to care in the examination of our patients, one case in particular comes to my mind. This patient had been in the Douglas county hospital for three months prior to my going on to the staff. It looked like progressive muscular atrophy; there was no use of the lower extremities. Superficially, it showed muscular atrophy. It had been so diagnosed by eminent men. I went through the history carefully, and found that which had not been discovered before, that she had been an alcoholic. Then she ran out in the rain and got chilled. Careful examination showed me that it was not muscular atrophy, but acute multiple neuritis. She was treated for this condition and entirely restored.

Dr. Coulter (in conclusion).-I agree with Dr. Barstow with reference to the necessity of a careful diagnosis, in fact careful examinations as well. We are not careful enough; we cannot make proper examinations for $2. We are liable to pass by the real trouble, unless we go carefully and systematically about our examinations. If these patients are seen early and their cases properly diagnosed, a certain per cent can be cured by persistent and careful treatment. The case related by Dr. Strong was, undoubtedly, as she said, one of peripheral neuritis, and yet seemed like one of muscular atrophy. The prognosis of the two diseases is entirely different. The atrophy can only be arrested when properly treated in its early stage.