are represented by reddish-gray patches or very firm areas of a lighter color. The cord, the pons, the crus, the cerebrum, and the cerebellum have all been found involved. Upon contraction of the fibrous connective tissue atrophy of the nervetissues ensues. The blood-vessels frequently reveal sclerotic

changes.

Symptoms. Three distinct types of this disease have been described: The cerebrospinal, the cerebral, and the spinal. In the majority of cases, however, the discase involves both the brain and the spinal cord; and hence the predominant type is the cerebrospinal. The first symptoms may appear after some mental or physical strain, the patient behaving as if affected by hysteria. There may be temporary aphonia, from which there may be speedy recovery, or numbness may occur in some part of the body. There may also be a sensation of deadness and of coldness, a feeling as of the pricking of pins and needles, or there is great loss of power in some part of the body, even with convulsions. These symp

toms may disappear for a time and reappear with increased severity. When the disease has been fully established, periods of remission may occur. A common type of the disease as described by Charcot shows the following symptoms: The patient develops spastic paraplegia, with exaggerated reflexes, with ankle clonus, and limited movements. An irregular jerky tension tremor occurs, nystagmus being a prominent symptom. Diplopia and paralysis of the ocular muscles are common. Scanning speech is prominent. There are paresthesia, tinnitus aurium, and vertigo. The mental faculties are blunted, and in some few cases apoplectiform and epileptiform convulsions may appear. Trophic changes arise late in the disease, the sphincters, however, remaining normal. Another variety of the disease is one in which the symptoms are more closely referable to the spinal cord, in which the cerebral manifestations, such as the vertigo and apoplectic attacks, the ocular symptoms, scanning speech, tension tremor, and so on, do not occur. Rarely are the knee-jerks absent.

Prognosis. The prognosis is unfavorable. The disease may last for a long time. The cases in which the spinal symptoms alone are present may last for twenty years or longer.

Treatment. The treatment is the same as in other forms of sclerosis. The salts of gold, silver, and arsenic have been

recommended.

TUMORS OF THE SPINAL CORD.

Tumors may arise from the membrane and from the cord substance. The following tumors have been found arising from the membranes: Lipomata, myxomata, enchondromata, fibrolipomata, sarcomata, and carcinomata. Sarcomata, as a rule, are primary, but carcinomata are always secondary. The tumors arising from the cord substance are, as a rule, primary, the following having been noted: Myxomata, fibromata, psammomata, sarcomata, fibrosarcomata, angiosarcomata, neuromata, and lipomata. Echinococcus cysts have also been found. As a rule, but one tumor has been found. Sarcoma and neuroma have occasionally been found multiple. Gummata have been noted. It is supposed that trauma may have some influence in the production of new growths.

Symptoms. The symptoms are those of compression and local irritation. At first the pain is local, associated with stiffness; later, atrophic paralysis associated with anesthesia and hyperesthesia occurs. Spasms with exaggerated reflexes and disturbance of sensibility are common. Paraplegia with paralysis of the sphincters is a late symptom. Prognosis. The prognosis is unfavorable, except in the cases of gummata.

Treatment. If the disease be of syphilitic origin, iodid of potassium and mercury are of use. Surgical interference is often indicated. For the pain opium and counterirritation are

necessary.

SYRINGOMYELIA.

Definition.-Syringomyelia is characterized by the forma tion of a cavity in the substance of the spinal cord owing to the breaking-down of certain nerve-structures.

Synonym.-Gliosis spinalis.

Etiology. The disease may begin after severe trauma to the spine. Some cases have been known to follow the infectious fevers, especially enteric fever, most cases, however, occurring between the twentieth and thirtieth years of life, and being slightly more common in males than in females. Nothing is definitely known of the etiology.

Pathology. This disease is regarded as a gliosis with degeneration of the central portion of the cord and hemorrhages, so that a cavity is formed in the central portion of the cord. It is to be distinguished from hydromyelia, which simply refers to

a distention of the central portion of the canal. The cavity in the cord in syringomyelia may involve the entire length, but more frequently it is localized to certain areas. The cavity formation frequently involves the upper part of the cord, the cervical and thoracic regions. A brownish gelatinous fluid is sometimes contained in the central portion of the cord.

Symptoms. The recognition of the disease depends upon the association of three important symptom groups: (1) Loss of the sensations of pain and temperature in any part of the body, the tactile sense being preserved in the same area; (2) trophic changes in the skin, muscles, bones, or joints; (3) progressive muscular atrophy, with paralysis. With these symptoms there may be associated spastic paraplegia or the symptoms of a transverse myelitis or the symptoms relating to involvement of the lateral, posterior, or all the columns of the spinal cord. The prominence of the symptoms will depend upon the distribution of the lesion. The course of the disease is chronic, the symptoms appearing gradually, and remaining stationary for years, death being due to some intercurrent affection, although in rare instances death has occurred from the rupture of the cavity. In a large number of cases there is marked curvature of the spine, either laterally or forward or occasionally even backward. The disease formerly called Morvan's disease is now known to be a variety of syringomyelia, as in all cases examined after death the cavity has been found in the spinal cord. The reflexes vary; they may be either lost or exaggerated, depending upon the situation of the lesion; and if the disease extend to the medulla, implication of the cranial nerves occurs.

Prognosis. The prognosis is unfavorable, the disease lasting for many years.

Treatment. The treatment is symptomatic. If the paralysis occurs, it should be treated as an anterior poliomyelitis. If there are marked trophic changes, they should be treated by rest, by mechanical appliances, and by surgical means. The sensory loss can not be remedied. Tonics may be

necessary.

DISEASES OF THE MEDULLA AND PONS.

PROGRESSIVE BULBAR PARALYSIS.

Definition. A disease of middle age, characterized by impairment of speech, phonation, mastication, and deglutition, which is both gradual and progressive, with increasing muscular atrophy.

Synonyms.

Labioglossolaryngeal paralysis; chronic bulbar paralysis; Duchenne's disease.

It is sup

Etiology. This disease rarely occurs before the forty-fifth year of life, and is more common in the male sex. posed that lead-poisoning and diphtheria may give rise to it. Exposure to cold, trauma, and syphilis have been named as etiologic factors.

Pathology. The muscular atrophy is limited to the lips, tongue, palate, and muscles of the larynx, and if spinal atrophy be associated, the muscles of the neck, shoulders, or arms are also involved in the process. The tip of the tongue frequently reveals very marked atrophy. The roots of the hypoglossal, glossopharyngeal, vagus, facial, the motor nucleus of the fifth, and spinal accessory may show distinct atrophy. They are of a grayish-red color and very much thinned. Changes are also encountered in the medulla oblongata. The ganglion cells in the motor nuclei are atrophied. The most marked atrophy is found in the nuclei of the hypoglossal, and is less marked in the nuclei of the vagus and spinal accessory. Changes have also been noted in the cord. Symptoms. The first signs of the disease are some involvement of the tongue, so that speech becomes indistinct, especially in the use of the linguals, such as "1" and "n." The lips soon become weak, and the patient has difficulty in pronouncing the labials. Whistling is impossible. Next the muscles of the pharynx and palate suffer. Saliva dribbles from the mouth; the face becomes motionless and without expression. Speech becomes impossible. There is total inability to swallow. Some atrophy of the muscles of the face also takes place. Sensory phenomena are not present; however, the throat reflexes are early lost, so that food finds its way into the larynx. There are slight, if any, changes in the electric reactions. The mind is not impaired; the patient, however, is apt to be emotionless. Progressive muscular atrophy is a

common association. The advance of the disease is progressive, although there may be periods of intermission lasting some weeks or months. The duration of the disease varies from six months to nine or ten years, the majority of cases lasting from two to four years.

Prognosis. The prognosis is unfavorable, especially so if the disease show itself early in life. The principal causes of death are inanition, bronchopneumonia (deglutition pneumonia), failure of respiration, and intercurrent diseases (croupous pneumonia).

Treatment. The general health of the patient must be maintained. Tonics, such as arsenic, iron, and strychnin, are useful. Great care must be taken to prevent food from finding its way into the larynx. In the later stages of the disease morphin hypodermically should be used to make the patient comfortable.

HEMORRHAGE INTO THE MEDULLA AND PONS.

Hemorrhage into the medulla and pons frequently occurs by extension or from the rupture of a bulbar blood-vessel.

Etiology.-Hemorrhage in this locality is due to the same causes that give rise to hemorrhage in general. Hemorrhage into the medulla is rare, and into the pons is also very rare as compared with hemorrhage into the internal capsule.

Pathology. The causes of this condition are similar to those of cerebral hemorrhage, and it may result from trauma, miliary aneurysms, meningitis, syringomyelia, or tumors.

Symptoms. As a rule, death occurs very rapidly—in from a few seconds to a few minutes-from interference with the cardiac and respiratory nuclei. There is loss of consciousness, most often without convulsions. In the rarest instances recovery may follow with symptoms of bulbar paralysis. When convulsions occur, they commonly begin at the onset of the affection. They are usually general and epileptiform in character, but the legs alone may be affected. Paralysis is often bilateral; rarely hemiplegia occurs. The pupils are "pin-point," but in rare instances may be dilated. Vomiting is common, the temperature is high,—from 105° F. to 106° F.,—and the respiration is of the Cheyne-Stokes type.

Prognosis. Recoveries are extremely rare. At least fourfifths of all cases are fatal. It should always be borne in