Original Communications.

CASE OF VARICOSE ANEURISM-ONE OF THE SINUSES OF VALSALVA COMMUNICATING WITH THE CAVITY OF THE RIGHT VENTRICLE.

G. G

By H. G. BEYER, M.D., M.R.C.S.,

PASSED ASSISTANT-SURGEON U. S. NAVY.]

-, a seaman in the United States Navy, aged thirty-three, and a native of the city of New York, was admitted to the Brooklyn Naval Hospital on December 24, 1881, at 5 P.M., in a comatose condition. At this time nothing could be ascertained about his illness.

It was impossible to obtain any information regarding his family history. According to the records of this hospital, he had an attack of adenitis, and was treated here for the same between the months of January and April, 1879. Dr. Ames, the surgeon of his last ship, informs me that, on August 11, 1880, he was admitted to the sick-list with traumatic orchitis, caused by a blow received from a handspike, and was ill for twenty days; that he was next admitted November 7, 1880, with acute rheumatism, affecting his left knee only; it yielded readily to treatment with salicylic acid, and was considered a light attack, patient not being sick enough to be confined to his hammock. September last, while in New York, on leave of absence, he suffered from an inflammation of his eyes, and was treated by an oculist there; it is presumed he also had a syphilitic history, dating from his early career in the service, but his record physically on board his ship had been excellent.

In this account no mention is made of the existence of heart disease, nor of anything that might lead one to suspect it, with, perhaps, the exception of his rheumatism. December last, while again on leave of absence, and living in a downtown boarding-house in New York, he was taken with violent vomiting, and sent for Dr. Simon J. Walsh, whom he informed of the fact that he had been on a "spree" in Boston lately, and that his sickness was probably the effect of that. Dr. Walsh made a careful examination of his chest and abdomen, and diagnosed mitral disease of the heart, with gastro-enteritis; for the latter affection, as he kindly informed me, he ordered bismuth. friends at the boarding-house also mention that on December 20th, the day preceding his sickness, while out walking with a friend, he was suddenly overcome by a fainting-spell, and would have fallen, had he not been supported by the person accompanying him; he was only partially unconscious, rallied quickly, and walked home. On December 23d, the day before his transfer to the hospital, Dr. Walsh found him sitting up, and, upon being told that he was "all right now," did not deem it necessary to continue his calls.

His

From all that could be learned, I found that Ghad been in the habit of going out daily, and had always been bright and cheerful until December 20th, the day of the fainting spell. On December 24th he lapsed into the unconscious state, during which he was brought to this hospital by Dr. Rufus Tryon, U.S.N.

On his admission, and while under the care of

Dr. Charles A. Siegfried, U.S.N., G- presented the following symptoms and physical signs, viz.: General surface livid, cheeks flushed; unconscious, but could be partially aroused; there was no paralysis, moved his head and extremities when pricked; pupils were evenly dilated; temperature, 97° F.; pulse at wrist was absent the greater part of the time, when present, scarcely perceptible; heartbeat only at long intervals, making one or two very tumultuous revolutions; loud murmurs with both sounds of the heart were plainly audible; breathing was frequent and noisy; was unable to swallow anything, and medicines were administered with great difficulty. A few ounces of urine were taken from him with a catheter, and found one-fourth albuminous, and very dark colored, from admixture of red blood-corpuscles.

The treatment consisted in external heat applied in the shape of hot blankets and internal stimulants. Disease of the heart was clearly diagnosed, and the existence of aneurism strongly suspected. Gexpired at 8 P.M., about three hours after his admission, never having spoken nor been roused from his unconscious state. The next morning, at the request of Dr. Siegfried, I made the autopsy.

Autopsy was made fourteen hours after death. Rigor mortis well marked; body well nourished and exhibiting signs of good muscular development; surface, with the exception of two small scars upon buttocks and sacrum, presented nothing abnormal; skull-cap normal.

Brain.—Membranes opaque and covered with recent lymph at base as well as over the vertex, and here and there the arachnoid was found adherent to the pia mater. The substance was intensely injected and blood was flowing freely from the puncta vasculosa on cutting open the brain; the ventricles contained but a slight amount of fluid; a clot was found in the superior longitudinal sinus; weight, fifty-six

ounces.

Diaphragm.-On right side at upper border of sixth rib, on left side in fifth intercostal space; but few ounces of dark-colored fluid in abdominal cavity and a lesser amount in right pleural cavity.

Heart.-Pericardium contained three and one-half ounces of a serous straw-colored fluid; heart flabby and but imperfectly contracted; valves sufficient; right auricle of a dark, purplish color, and firmly contracted; muscular substance of a pale reddish brown color; the endocardium smooth and glistening but opaque, and a very copious deposit of recent lymph was found in the cavity of the right auricle. About one inch below the posterior segment of the semilunar valves of the pulmonary artery, a well-defined and perfectly round ulcerative opening, of about three-eighths of an inch in diameter, and showing recent granulations, presented itself to view. This opening was very nearly in the centre of a little thin walled pouch, projecting from the posterior wall of the right ventricle into its cavity. A probe passed into this opening, and pushed slightly backward, upward, and to the right, was seen to emerge above the right anterior segment of the semilunar valves of the aorta. On farther examination it was found that the right anterior sinus of Valsalva was very much dilated, and formed a pocket, the size of a walnut, which contained a fibrinous clot. The little finger passed into this pocket could almost directly be pushed on into the right ventricle, through the ulcerated opening above mentioned. On further examining the left anterior sinus of Valsalva, it was also found dilated; this

Lungs.-Extensive old adhesions, costal, and diaphragmatic on left side, and hemorrhagic infarction of entire lower lobe, the rest was highly edematous and congested; right side free, except slight recent adhesions over upper lobe with intense general congestion and oedema.

Spleen.-Congested and but slightly enlarged, weighing eight ounces.

Kidneys.-Left, eight ounces; right, six ounces; capsule easily detached; both were congested and fatty.

Intestines.-Stomach, large and small intestine deeply injected and filled uniformly with a coffeecolored, semi-solid, gelatinous mass, and covered throughout with masses of recent lymph. The large intestine, which was removed to within an inch of the anus was, at certain places, firmly contracted to the extent of from one to eight inches, there being no stricture. From the sigmoid flexure down to the sphincter, it was uniformly contracted, the lumen hardly admitting my little finger.

Liver.-Weight, four pounds and four ounces; was of a very dark brown color and congested, and of a granular outside appearance; apparently cirrhotic; gall-bladder filled with bile, and normal.

Microscopical examination was made both from fresh material, mounted in a one-per cent. solution of chloride of sodium, and from hardened tissues

stained with picro-carmine and mounted in glycerine.

Heart.-Muscular fibrillæ show here and there foci of fatty degeneration; there is a very thick layer of subpericardial and subendocardial adipose tissue, extending into the muscular substance of the organ, surrounding the blood-vessels, and also, to a certain extent, the muscular fibrillæ; connective tissue seems slightly proliferated; blood-vessels show a distinct thickening of the adventitia, also media to a moderate extent, with a corresponding puckering of the intima; in some places they appear irregularly compressed, being surrounded by large clear spaces, evidently indicating serous effusion. Near some of the largest arterioles, I notice a newly formed tissue, rich in nuclei, and the cells composing it are partly round, partly spindle-shaped; this tissue does not seem to surround the calibre of the vessels completely, and although adjacent to, and apparently continuous with the adventitia, can hardly be called part of the latter.

Aorta.-Nothing abnormal was observed in the coats of the aorta.

Kidneys.-Capillaries and veins choked with bloodcorpuscles; connective tissue moderately proliferated; renal epithelium fattily degenerated."

Liver.-Blood-vessels crowded with blood-corpuscles; connective tissue increased considerably, the resulting cirrhosis being of the multilobular variety of Dreschfeld, or the cirrhose vulgaire of Charcot, described by Hanot; the corpuscular elements of the liver show granular and fatty degeneration, also a good deal of pigment.

Remarks. Varicose or communicating aneurism was first defined by Stokes as that variety of the disease in which blood passes from one portion of the vascular system to another. In accordance with this definition the present example may, I believe, be safely described under that head.

I have been able to find but two examples of varicose aneurism that bear a real resemblance to the one in hand. Hope, quoted by Hayden, in 1839, published a remarkable case of aneurism of the aorta immediately above the valves, communicating with the right ventricle by two apertures; the symptoms and signs which followed a strain in lifting a weight, and a "creak in the heart," accompanied by faintness, were lividity, oedema, jerking pulse, purring tremor, double murmur, and a continuous rumble to the left of the sternum from the second to the fourth rib.

The second case came under the notice of Dr. Hayden himself through his friend, Dr. Stokes, and is described in full on page 759 of the second volume of Dr. Hayden's work on "Diseases of the Heart and Aorta." This aneurism was of the size of a tennis-ball, arising from one of the aortic sinuses, and communicating with the right ventricle by an aperture of the size and shape of a "shirt-buttonhole." The symptoms were general congestion and oedema; physical signs, frémissement, with a loud and double murmur at midsternum; the case being under observation for some time, the diagnosis of aneurism, opening into one of the ventricles, was presumptively made.

The latter instance, to which my attention was very kindly called by Dr. G. L. Peabody, only differs from my own in this, that it was somewhat larger, only one of the aortic sinuses was involved, and the aperture by which the aorta communicated with the right ventricle, was of the shape of a "shirtbutton-hole." In my case, the sac was smaller, two

of the aortic sinuses were involved (although no communication existed between them), and the opening was perfectly round, and its margin beset with recent granulations, indicating ulceration.

Cases of varicose aneurism having a more remote relation to the present one have been reported at various times and in different countries by Beauchene, Wells, Curling, Munro, Reid, Thurnam, Peacock, Rokitansky, McDowel, and others.

The present example of varicose aneurism, then, derives its interest and importance mainly from the rarity of the pathological specimen which it has furnished us in the shape of the heart. It has been forwarded to the Surgeon-General, Philip S. Wales, U. S. Navy, who will probably place it in one of the museums at Washington, D. C.

As to the causes of the disease in the present instance, it is reasonable to suppose, that rheumatism, syphilis, and the free use of alcoholic stimulants, may have more or less predisposed to the trouble, while the exciting cause was doubtless an injury. The sudden violent physical exertions incident to his position of gunner's mate on board of a man-of-war warrant this conclusion.

With regard to the symptoms which G- presented during life, the fainting-spells which he experienced while out walking, the day before the diagnosis of heart disease was made, possibly marks the time of occurrence of perforation of the aneurismal sac. The fact that the perforation of the aneurismal sac was of recent date finds also partial support in the character of the granulations covering the margin of the aperture.

Cause of death.-Paralysis of right heart from over-distention, and the great general disturbance in the nutrition of all the internal organs and viscera consequent thereon.

HEART-LESIONS IN RHEUMATIC FEVER.

BY W. S. CHEESMAN, M.D.,

AUBURN, N. Y.

THOUGH Systematic writers are careful to declare that, in rheumatic fever, pericarditis and endocarditis are as truly local manifestations of the general disease as are the joint-lesions, yet it is their custom to treat of them as complications, along with pleurisy, pneumonia, and peritonitis. Thus the notion has gained currency that these heart-lesions are accidents, and to be prevented by special local or general medication. In view of the practical as well as theoretical consequences of this error, it seems important to emphasize the idea that heart diseases are not mere complications of rheumatic fever, like ophthalmia in cerebro-spinal meningitis, or hypostatic pulmonary congestion in typhoid fever, but are local expressions of the disease process quite as characteristic, if not so common, as arthritis.

It may be worth while to inquire upon what facts this conception is based. In the first place, upon the frequency with which acute rheumatic arthritis is attended by heart disease. Especially is this noticeable in the young. Said Watson: "With perhaps one exception, I never knew the disease (rheumatism) to occur in unequivocal form before puberty, without its being attended with inflammation of the lining or investing membrane of the heart." Since his day all observers have testified to similar purpose, if not in so sweeping generalization. In adults, also, rheumatic heart disease is suffi.

ciently common, though its frequency is variously estimated, different writers claiming its occurrence in from seventeen to fifty-five per cent. of the cases. Surely, when any lesion is so usual a concomitant of a disease it rises above the rank of an accidental complication to the importance of a characteristic local manifestation.

And this is still more plainly suggested by the frequently coincident appearance of heart and joint lesions, and especially by those cases wherein the heart affection precedes the joint trouble, or in which it is the only local evidence of the rheumatic disease. That such instances do occur is admitted pretty generally. I have myself reported a case of rheumatism of the pericardium which existed two weeks before any joint affection occurred to stamp its character, and which promptly yielded to the salicylate of soda (see MEDICAL RECORD, November 27, 1880). I can now give notes of two analogous

cases.

CASE I.-I was called to see a boy, aged sixteen, who complained only of headache and malaise. Examination of the chest was negative. Temperature 101° F., and not reducible by quinine. On the third day I made out a mitral systolic murmur, had the patient put to bed, and carefully examined his heart twice a day. The temperature remained elevated, and the physical signs of heart disease became more and more intense. The interpretation of the case as one of rheumatism of the endocardium alone did not occur to me until, after a week's illness, the right knee became swollen and painful. Then I recognized the condition, and salicylate of soda promptly reduced the temperature and stopped the arthritis. The patient recovered with a damaged heart, which, when last examined, was undergoing compensatory hypertrophy.

CASE II. Twenty-four hours after being caught in a shower while rowing, a gentleman observed a slight creaking sound as he was sitting quietly reading. For some time he gave it no attention, but, on finally seeking its source, he noticed that it was synchronous with his own pulse, and, in short, proceeded from his own chest. It was loudest when he leaned forward. No pain nor any other symptom was observed. The next day, in addition to hearing, he could distinctly feel an intra-thoracic friction. He was examined by a distinguished New York diagnostician, who clearly heard, at a distance of four feet from the patient's chest, a sound which resembled the crunching of snow under foot on a cold winter day. It was loudest when he leaned forward, but was to be heard and felt at all other times. The diagnosis was of pericarditis without effusion, and the patient was ordered to bed, and to take ten grains of sodic salicylate every four hours. Some palpitation was felt that evening, but recovery was rapid, and on the fifth day the friction was felt for the last time, during forced expiration, with the arms above the head.

I refrain from comment on this interesting case, save to urge the point that here apparently was a rheumatism of the pericardium uncomplicated by arthritis, a view concurred in by the well-known medical gentleman who saw the case.

In consideration of these facts, probably none would be inclined to dispute the position clearly enunciated by Flint, that while it may be "convenient to speak of these affections as complications, they are, properly speaking, to be reckoned among the local manifestations of the disease; that is, they are dependent on the same internal deter

mining cause to which the affection of the joints is to be referred."

I am not aware, however, that any one is willing to accept the logical consequence of this position, viz., that so long as the rheumatic process continues, it were as idle to think of preventing its manifesting itself in the endocardium or pericardium, as to seek to protect any particular individual joint from its attack. If the general disease may find local expression in inflammation of any or all of these parts, there might reasonably seem quite as much hope of preserving whole by topical or other measures the right wrist (let us say) as of thus keeping the heart sound. Arthritis, and not seldom cardiac diseases occur with pyæmia: who would pretend to protect the heart while pyæmia survives? In like manner, the vaunting of any treatment as able to shield the heart, while it does not destroy the rheumatic peison which attacks the heart, seems unphilosophical. First antidote that poison, and then, and not before, should the lining and enveloping membranes of the heart, as well as the other serous structures, be thought safe.

These à priori considerations are, it must be confessed, not contradicted by facts. As might have been expected, in spite of all the means used to prevent them, heart diseases occur in rheumatic fever with about the same frequency as when Gull and Sutton investigated the matter by the exhibition of mint water, and were led to urge the expectant treatment of rheumatism. It has been the boast of every new plan of therapeusis that it met this crying need, yet neither belladonna plasters to the precordium, nor blistering, nor saturation with the alkalies, nor any other measure, enjoys the confidence of the profession. If the recent debate of the London Medical Society proved nothing else, I believe it proved abundantly that we have no means for averting the cardiac manifestations of acute rheumatism, just as we have none for averting any single arthritic manifestation-except by stopping the rheumatism. Herein would seem to lie the only rational hope to check the disease before the heart can become affected. It must be remembered that cardiac trouble, when it occurs at all, begins usually in the first week of the disease; hence, if we are to prevent it, treatment must be instituted at the outset, and the disease aborted as speedily as possible. When it is considered that patients seldom apply to hospitals in the first week of their sickness, we can understand why the salicylates, which certainly are our most prompt anti-rheumatic agents, are not shown by hospital statistics to be very much more efficient in keeping the heart structures whole than are the older forms of treatment.

If this reasoning be well founded, it were not too much to expect that we should hear no more of those various plans of local or general treatment which medical literature urges for the special protection of the cardiac structures in rheumatic fever; and it would seem the plain duty of the profession, laying aside such hopes as vain and unwarrantable, to address itself to the all-important task of checking, at the earliest possible stage, the general disease whereof lesions of the heart and of the joints are alike the local manifestations.

PROFESSOR HAYEM, of Paris, has been transferred from the Chair of Therapeutics to that of Pathological Anatomy, vacant by the nomination of Charcot to the new Chair of Nervous Diseases.

ALCOHOL AS AN ANESTHETIC. BY J. T. SEARCY, A.M., M.D.,

TUSKALOOSA, ALA.

WHAT Constitutes the physiological action of alcohol in the body is always a question full of interest and of practical importance. The study of the mode of its action is interesting to the physician in his administration of it as a medicine. He is also interested in it as an agent that brings to his door as many, if not more patients than any other one cause. The world at large, considering the immense interests at stake, are continually demanding of sanitary medicine information as to its actual value as a beverage-for which object it is mostly used-until it is, in fact, one of the "livest" questions of the day. It is very evident to one reviewing the subject, that professional opinion has been "changing base decidedly, even within the past ten or fifteen years. From time immemorial it has been customary to set down alcohol as a "stimulant" in the strictest sense of the term. Now we find many of the best men of the profession declaring that it is not a stimulant in any of the stages of its action. We find it now fighting tenaciously for its own claims as a nutrient, though it is very evident it is driven very strongly to the wall to prove them, and there are many ready to deny that it is in any sense a food.

I do not propose to go into the argument to prove its stimulating or its nourishing value, but briefly call attention to its present status as an anæsthetic.

In the first place, alcohol is born in the same retort, and has physical properties and a chemical composition so similar to a large number of agents of modern discovery, whose effects in the system are called anæsthetic and nothing else, that naturally we would assign it to that family, and probably this would be more readily and rapidly done if the cautious conservatism of medicine did not always move slowly. More than any other profession it is "addicted to swear in the words of a master."

Ethylic alcohol is the form most frequently met with and used. It occurs in all the popular drinks of the day, in very variable proportions, ranging all the way from two or three to fifty per cent. We may, in a practical point of view, regard them all as mixtures of alcohol and water, associated with other substances of minor importance.

Compared with the anesthetics in most frequent use-as chloroform, chloral, ether, nitrous oxide, and the like-alcohol seems to differ from them not so much in the salient points of its action as in its tardiness and slowness. Each one is of course peculiar to itself in minor points, but their leading features are very similar. Alcohol is slower in its action than chloral, which is slower than ether, and ether than chloroform, and chloroform than nitrous oxide. This tardiness of action renders alcohol the least dangerous; and, although called alcohol by the Arabs because of its subtilly, it is really the least subtile of them all. It seems, though, to have been very subtle in assuming titles and attributes that have served to cover up its true character. Because of its tardiness of action, its different stages are more open to inspection, and make it an excellent "prototype" by which to study anaesthetics.

"Anæs

The recent number of Wood's Library, on thetics," by Professor Lyman, is a most excellent work, taking up the whole subject, and the following reflections have been most profitably informed, supported, and encouraged by its perusal.

Before we consider the anaesthetic action of alcohol, a condensed review of some of our physiology is relative to the subject.

Tissue-change, whether you call it cell-action, molecular motion, or what not, constitutes the essential for life. To support and continue this action harmoniously, "naturally," is the direct and the indirect object of the greater part of the machinery of the body. The magnitude of these processes, silently, and in health harmoniously going on, we are very apt to overlook or forget. Action-cellular, molecular, tissue action-constant, continuous, and harmonious, in accordance with natural processes, constitutes healthy life. And we might be bold enough to say that disturbed natural action, whether it go so far as to produce destructive changes visible to the eye or not, makes or constitutes disease.

The blood carries the pabulum to support these natural processes, and is the vehicle to remove the waste products. The most important organ in the body is the nervous system-the cerebro-spinal, sympathetic, vaso-motor, and all are a whole indissolubly interwoven and bound together. Control is its principal function. It controls and regulates not only the supply of blood to the tissues, but even regulates, to a greater or less extent, cellular action itself. The cerebrum, with its hemispheres, its gray and white matter, is the head-centre, its cortical portion principally cellular, and its white matter principally composed of nerve-fibres. Lying on the plate before you, it appears to be a very homogeneous mass, when in truth it is the most complex of all complexities. Its cortical portion, principally cellular, "having functions past finding out," is the meeting ground between mind and matter. Every cell appears to be connected with every other cell by the nerve-fibres in the whiter portion, and also through them and their connections unites all nervous structures into one, and makes the body a whole. So intricate, complex, and multiplied are the parts that "with how much art the windings run and where the regular confusion ends" is a most perplexing question in physiology. And the multiplied complex character continues even outside the cranium in the rest of the nervous system, descending in order of importance. The whole body is united into a complete whole by the nervous system, which exerts its control over all. Its several portions differ in cellular structure and in molecular motion according to function.

We have some agents, none more decidedly than the anaesthetics, that make exhibition of their properties by influencing the nervous centres. The study of the action of such drugs is particularly interesting, and the explanation of it does not appear to be nowadays all theory. The order and the degree in which certain portions of the nervous system are affected, is beautifully explained by the paralyzing influence of such drugs over their cellular motion, more here and less there, as the natural motions of particular parts are more or less interfered with by the different agents used.

On the lowest forms of living existence-simple protoplasm-alcohol produces instant death, unless largely diluted. Apparently it does so by its affinity for water. It will become "hydratia" if it has to take the water from living sources. Colloidal albuminous substances, not living, are coagulated by it in the same way. If largely diluted to at least twenty per cent. in the watery solution, it does not destroy structure, but arrests, either permanently or for a time, the natural molecular motion. It

produces paralysis. The stronger the solution the more decided and rapid the effect, and vice versa. The antiseptic property of alcohol when applied to wounds, and, in the arts, its property to arrest fermentation, are due to this. It renders dormant, if it does not entirely destroy, the germs whose "catalytic" presence makes the fermentation in the one case, and does injury to reparative action in the exposed tissues in the other. The antiseptic properties of alcohol were known before the days of the good Samaritan, and are still highly endorsed by many surgeons, though carbolic acid and other substances supplant it for many reasons.

Taken into the stomach the same "hydrating" affinity of alcohol shows itself at once, if the stronger mixtures are taken. Hence, when this is the case, we find the mucous coat "shrivelled," "corrugated," and "hardened." It may go, if not sufficiently diluted, not only so far as to produce mucous catarrh in that organ, but also injure the deeper tissues; and gastritis in all its phases we see following its use. Because of the same property many explain its hurtful effects upon the liver, which it reaches immediately after leaving the stomach, and through which it is sifted by the innumerable capillaries of the portal vein. Also the blood-corpuscles change shape, and the fibrin is sometimes seen coagulated for the same reason.

Entering the circulation, one of the first apparent effects of alcohol on the nervous system is its paralysis of vaso-motor control. It reaches in the capillaries that portion first, though its transit through the body is so rapid that it reaches the higher centres almost as soon, and we see them exhibiting disturbed action. The result of vaso-motor paralysis is to dilate the capillaries, hence there is increased flow of blood to the periphery, and the heart takes on increased action to supply the demand. The increased vascular supply of blood to the surface or to the capillaries seems to produce an increased degree of temperature, particularly of the external parts, the deeper ones not changing. It is just here that the stimulating properties of alcohol come in, if it have any, but ether or chloroform can put in the same sort of a claim, though the stages of their action are much shorter. If there is in the first flush of blood-supply increased general tissuechange and there is some increased warmth, the specific paralyzing effect soon follows and the general temperature is lowered.

The higher nervous centres show disturbance according to function. In the brain, mental aberration exhibits itself, excited action, and not a complete balance of mental control, is shown. The higher mental powers seem to topple first. Reason and self-control lose their hold on man in proportion to the amount of the drug taken, and he, in a certain sense, is left to the impulses of his lower instincts. We have every degree of loss of mental control, ranging all the way from a slightly hilarious, talkative, silly, or stupid condition, to complete loss of all consciousness. As might be expected, good normal brain-power, representing force of mental tone and control, peculiar to and different in different individuals, will give varying exhibitions in the loss of such control. The drinking man is noted for all sorts of departures from his normal condition of mental balance, and weaker peculiarities of mind are shown in greater prominence when they exist. Descending in the order of importance in the nervous system, the centres of special sense, of general sensation and of motion and of the various " "vegeta