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Case XXIV.—This case is of especial interest, because the history was taken many years ago by one of my assistants, long before I had thought of the diagnostic points to which I am calling attention in this paper; as will be seen, the peculiar headache and insomnia are only incidentally mentioned long after the patient had been under treatment. Male, aged thirty-seven. Gives a history of a soft chancre twelve years ago, and had syphilis when seventeen years of age. Has not been able to work for three months, and during the time has had a severe pain, particularly in the right side of the head, which is described as constant, increasing at times. There is anosmia. Paræsthesia of the lower extremities, most marked upon the left, slight tremor of the tongue, knee-jerk normal, vision normal, urine normal. There are tender points over the territory of the right side of the head. Has had what he describes as slight spasms in the left leg without loss of consciousness except in one attack. All the sensations were normal. This patient was put on iodide of potassium, 15 grains, three times a day, on August 19th. On August 27th, headache is much diminished; August 31st, still much improved; pain in the head has very nearly ceased. September 3d, has still slight pains in the head. October 12th, improvement continues, although at times there are constant headaches, lasting for a day or two. Under this date, for the first time it is mentioned that for three days past he has had no sleep in consequence of severe headache. October 16th it is stated that the headache is still severe and he sleeps badly. Patient then passed from under observation, and the further history is not known.

CASE XXV.-Male, aged forty-four years. Twenty-two years ago contracted syphilis whilst a sailor, and says that he has secondary eruptions, but was treated locally. He is a gateman on the elevated road, selling tickets sometimes. Finds he can give change for ten or twenty minutes correctly, when he becomes confused, and is totally unable to attend to his business. Has attacks of partial unconsciousness of short duration, and in these he sees people, knows where he is, but is unable to talk coherently, or speak a single sentence. He had three epileptic attacks of the grand mal type some years ago, in which he lost consciousness, bit his tongue, etc. Had local epileptic convulsions up to six years ago. This patient gives a history several years ago, the exact time not being stated, of severe headaches, with marked insomnia. He passed into a condition of dementia, but has made a fairly good recovery with large doses of iodide and mercurial inunctions, and has for several months past been attending to his business correctly.

CASE XXVI.-Female, aged twenty-seven years. There is a history of maternal migraine, but otherwise the family history is negative. Patient has been married eight years; has two children, one six and one two years old. When the youngest child was six months old, the mother began to have attacks of twitching in the left side of the face at the angle of the mouth, followed by convulsions, in which she fell to the floor, with general convulsive movements. On coming out from these she was stupid and passed into deep sleep. The attacks were always the same. She has headaches over the top and brow, at times severe, which are much worse at night, and often cause complete insomnia. Never had any headache until after the aforesaid child was born, and this child is said to have had an eruption on its lips and

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under the nose, with “snuffles," whilst its eyes have been in a state of chronic inflammation, and it has vertebral caries, for which it is wearing a plaster jacket. There has been one miscarriage since, but she has also had one healthy child born. As this patient is seven months advanced in pregnancy, and has only recently come to my clinic, it is impossible to speak of the result.

CASE XXVII.- Male, aged twenty-six years. Comes to the clinic for the relief of headaches and a great sense of fatigue. His headaches are continuous and worse at night, and until recently were associated with obstinate insomnia. Has overcome the insomnia by treatment, but is dependent for sleep upon drugs. Has an interstitial keratitis that is apparently syphilitic, and admits having had syphilis three years ago, but does not know of any secondary symptoms whatever. Was under treatment for it about two months. Had trouble with his eyes exactly similar to present condition two weeks after he contracted syphilis. This patient is still under treatment, but has markedly improved in about three weeks, although it is as yet too early to positively speak of the result.

In tabulating these cases I have arranged them under the headings of pseudo general paresis, hemiplegia, basilar meningitis, mania, hallucinations, cephalalgia, intra-cranial syphilis, paralysis of the left arm and leg. This may at first sight seem to be a rather indefinite classification, but when it is borne in mind that the lesions of intra-cranial syphilis affect every portion of the brain and its meninges, and cause such varying symptoms, it will be seen that no other method of classification is feasible except that of selecting prominent symptoms. By pseudo general paresis I mean that malady to which Morel-Lavallée and Bélières have recently called attention in their most excellent and important monograph,' to which the name was given a number of years ago by Fournier, and which the former gentlemen have shown conclusively not always to consist of the lesions of a true general paralysis (although this may sometimes be the case), but generally to have as a pathological cause focal lesion of the cortex or subcortical substance, or syphilomata setting up cortico-meningeal adhesions and alterations. By the term basilar meningitis I have intended to designate those conditions which autopsies have again and again demonstrated to be due to a gummatous infiltration of the membranes at the base. The other terms explain themselves.

Of these 27 cases the average age was thirty-five and two-ninths years, the maximum being fifty-two years and the minimum being twenty-four years. In 13 there was complete recovery, that is in 461% per cent.; in 4 there was partial recovery (15 per cent.); in 5 the results of treatment were unknown, because the patient passed away from observation, and in 1 the patient is still under treatment. The males were 20 in number and the females 7.

1 Syphilis and Paralysie Générale. Paris, 1889.

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Pseudo general paresis.
Mania.
Hemiplegia.

Pseudo general paresis.
| Basilar meningitis.

Neoplasm Gasserian ganglion.
Hallucinations.
Basilar meningitis.
Double hemiplegia.
Hemiplegia.
Cephalalgia.
Intra-cranial syphilis.
Hemiplegia.
Intra-cranial syphilis.
Pseudo-general paresis.
Hemiplegia.
Paralysis of arm and leg.
Cephalalgia.
Cephalalgia.
Pseudo general paresis.
Cephalalgia.
Hemiplegia.
Pseudo general paresis.
Basilar meningitis.
Pseudo general paresis.
Epilepsy.
Cephalalgia.

Unknown.
Recovery.
No improvement.
Partial recovery.

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I therefore maintain that in many cases of syphilis, constituting a majority of those which have come under my observation, there have been symptoms of a cephalalgia that is quasi-periodical, occurring mostly at night, though occasionally in the afternoon or morning, with marked insomnia, and that when any paralytic or convulsory symptoms supervene, this headache and insomnia suddenly disappear. From these facts I would assert that the occurrence of cephalalgia and insompia with these characteristics is diagnostic of intra-cranial syphilis. I would furthermore affirm that the occurrence of hemiplegia in an individual under middle age, with or without this insomnia and cephalalgia, should render us extremely suspicious of syphilitic causation. This insomnia and cephalalgia generally belong to the early stage of intra-cranial syphilis, although they are to be found in addition in the primary, secondary, or tertiary stage of the general syphilitic infection.

I have never been able to make a post-mortem examination in any case in which the cephalalgia and insomnia were the only symptoms, and I cannot, therefore, state anything positive as to the exact pathological lesions which cause these two symptoms. It is reasonable, however, I think, to assume that they are due to the well-known gummatous infiltration of the meninges, because the pathological alterations of the cerebral and cerebellar substances alone do not usually give rise to pain except when they are the site of neoplasms, and not always then, and also because this is true of the different forms of endocarditis. Another fact that is perhaps confirmatory of this theory is that I have never yet seen a case with the symptoms alone of the peculiar headaches and insomnia that did not yield promptly to vigorous anti-syphilitic treatment.

I am perfectly well aware that the pathognomonic symptom in medicine has gone out of fashion, as time has shown that every one of these 80-called signs has proven to belong to more than one disease. Nevertheless, I think it is true that pathognomonic groups of symptoms have held their own in a large degree, as in typhoid, pneumonia, locomotor ataxia, general paresis, etc. I would, therefore, invite the careful attention of the profession to this group which I have just detailed, simply saying that I bave never seen it in a case that was undoubtedly non-syphilitic except in one single case of acute bulbar paralysis. I cannot, therefore, resist the conviction that it is of great significance. 6 East FORTY-NINTH STREET, New YORK.

OBSERVATIONS UPON THE ANATOMY AND SURGERY OF

THE URETER.

By A. T. CABOT, A.M., M.D.,

OF BOSTON.

The observations which follow are the result of some investigations upon the anatomy of the ureter, made with reference to its surgical accessibility in different parts of its course. They were undertaken with the especial object of determining how best to reach and remove stones impacted in the ureter.

In the remarks which follow the writer takes it for granted that, if possible, it is always best to use an extra-peritoneal incision for the removal of a stone. The ureter is so thin-walled, especially when dilated by the retained pus and urine behind a stone, that if it is opened within the abdomen the closure of it by sutures must always be a doubtful and hazardous undertaking,

If animal sutures are used, the danger that they will be too soon absorbed is great, while silk sutures introduce the possibility of secondary stone-formation.

The writer has been able to find but one instance of a ureter sutured within the abdominal cavity (Cullingworth),' and in that case, although it was reported that there was no yielding of the wound in the ureter discoverable at the autopsy, still, as the patient died on the fourth day, it was rather too soon to say whether the sụtures were going to hold or not.

The ureter, leaving the pelvis of the kidney by a funnel-shaped opening, runs downward on the anterior surface of the psoas muscle, crosses the common iliac artery and vein at the entrance of the pelvis, and then running in the recto-vesical fold of the peritoneum converges toward the opposite ureter, and enters the posterior wall of the bladder. Here in the male it crosses the vas deferens. The opening through the wall of the bladder is more or less of a valvular one, as the ureter, after penetrating the muscular coat, runs for some half to three-quarters of an inch between the muscular and mucous coats before it actually opens into the bladder. The opening into the bladder is somewhat smaller than the rest of the canal.

In the female the ureters pass around the neck of the uterus, which explains the reason that an increase in the size of the uterus causes a mechanical impediment often to the passage of the urine. As the ureters approach the pelvis in the lower part of their course through the abdomen, the left ureter lies close to the spine, and in the angle between the body of the vertebra and the psoas muscle. On the right the ureter is somewhat further separated from the spinal column by the interposition of the vena cava inferior. The vein and ureter lie in close apposition.

While this description' serves as a fairly reliable guide to the ureter in most parts of its course, still in a surgical search for the canal deep in the tissues--particularly if the subject be a fat one-it is extremely hard to find the lax tube, and to recognize it in its collapsed condition. Therefore anything which enables the surgeon to locate the ureter any more exactly may be of great aid in his search. There is a relation of the ureter to the peritoneum which I cannot find mentioned in any description of its anatomy, a knowledge of which will greatly simplify this search. This is the fact that the ureter is adherent to the peritoneum," and always separates with the peritoneum as it is stripped up from the parts behind. The reason of this adhesion of the ureter to the peritoneum I sought by making microscopical sections across a ureter separated with its peritoneum and hardened in alcohol. A study of these sections showed that the ureter was bound to the under surface of the peritoneum by fibrous bands, which explains this intimate connection of the ureter with the membrane over it.

| Trans. London Pathological Society.

2 Taken from Hyrtl. 3 Twynam alludes to this adhesion of ureter to peritoneum.

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