also vomiting and staggering to the left side. He had pain in the occipital region, and pain and tenderness of the right occipital bone. There we made a diagnosis of tumor in the cerebellum on the right side, with destruction of pons fibres and staggering to the side opposite to the tumor, and we found the tumor after death. So conditions of the cerebellum, affecting the terminations of this nerve from the semilunar canal, will cause vertigo. There may be an affection of the nerve going up through the middle peduncle of the pons from Deiters's nucleus to the termination of the tract in the vermiform lobe in the cerebellum, but if that is involved there will not be deafness with the vertigo. Now, Ménière was not familiar with all these details of nervous anatomy, and, while he presented as much as was known in his day, he did not know these facts. Hence in all cases a sudden onset of vertigo, associated with pain and disturbance of hearing, was referred by him to the ear; but it is really, in many cases, due not to hemorrhage into the semilunar canals, as he supposed, but to lesions in the pons or cerebellum. There is nothing more difficult to determine than the location of the lesion in these cases. I am not sure that this man has trouble in the cerebellum, or that he has any organic disease, but the sudden onset suggests it. Cases of marked disturbance of equilibrium may be caused by functional disorders ; hence we see cases of neurasthenia and anæmia with these symptoms markedly developed. So, too, we have vertigo of gastric origin from irritation of these same nerve-centres in the pons reaching them by way of the vagus nerve. In such cases there is rarely any deafness. I have seen a number of cases where the patient has been deaf several years or months before the onset of the other symptoms: so you cannot always bring deafness into connection with the vertigo and headache. In this man the conduction of sounds, as tested by the tuning-fork, shows that the acoustic nerve is diseased. When we send a galvanic current through his acoustic nerve, his hearing-power is increased, but the current increases the vertigo. These facts lead me to think that in his case we have to deal with a central affection, not merely with a hemorrhage into the semilunar canals. It is a very difficult thing to determine whether the trouble is in the ear, or in the acoustic nerve, or in the cerebellum, or whether it is functional or organic so the physiology is interesting, but the diagnosis is a very difficult one to make. As to treatment, almost any form of vertigo can be relieved by giving the patient potassium bromide in ten-grain doses three times a day.

was.

PARETIC DEMENTIA.

CASE IV. This man comes complaining of his head. His wife tells us that he cannot talk as well as he used; he thinks he was well until four months ago. The trouble in speech came on suddenly. He can repeat the letters of the alphabet. I ask him to repeat the words "Third Artillery Brigade," and, you see, he does so quite awkwardly. As his tongue is projected, you notice a very marked tremor in it, and not only that, but also a more or less marked trembling about the lips and face. There is tremor on intention; the movement increases and spreads up to the sides of the face, becoming very much more marked; his hands tremble, the knee-jerks are increased; he walks as well as ever; his memory is not so good as it In making the diagnosis of brain-disease, you have to get at the symptoms in an indirect manner. When a man who is questioned as to the duration of his illness, which dates back but four months, asks his wife for the information, you can rely upon it that in that particular patient there is some defect of memory. When you ask a patient if his memory is good or not, he may not be conscious of defects. Many will deny the imputation of loss of memory, and say they recollect things, but if they appeal to others, as this man asks his wife, you may be certain there is some defect. This man becomes excited easily, his face flushes, and he loses patience at the least provocation. He laughs at the silliest things. He never cries; though he feels depressed a good deal, and his despondency increases as he sits brooding at home. A lack of mental control is quite evident. There is only one other thing to notice, and that is the anxious expression about his eyes. His wife has noticed this. You have also noticed the flatness about the face, and the lack of expression, unless he is excited, when there is an over-action. These symptoms, taken in connection with the tremor of the tongue, the peculiar tremor of the hands, and the lack of memory and self-control, constitute basis enough for the diagnosis of chronic encephalitis or inflammation of the cortex of the brain, the ordinary name for which is paretic dementia, or general paresis, or, commonly, softening of the brain. Do not forget that in such cases you must find both physical and mental symptoms before your diagnosis is sure.

LESIONS OF THE POSTERIOR COLUMNS IN THE

MEDULLARY SCLEROSIS OF ATAXIA.

CLINICAL LECTURE DELIVERED AT THE PARIS MEDICAL SCHOOL.

BY PROFESSOr dejérine,

Physician to the Hospice de Bicêtre; Professor (agrégé) in the Paris Medical School.

GENTLEMEN,-You know what lesions are found in the spinal cord in subjects who have presented more or less of Duchenne's malady during life. The sclerosis of the posterior columns and the atrophy of the corresponding roots always exist, but, while the characteristic features of these lesions have been known for a long time, their exact pathology is still under discussion. There are two things to consider in the medullary lesions of tabes,—their nature and their topography. It is this last that it is especially important to study. It is just here, as in all cases of sclerosis of the spinal cord, that we should devote our attention. Friedreich's malady is an exception: we proved with Dr. Letulle, in 1890, that in that disease the nature of the lesion does not present anything special.

In tabes, the lesions are found in the neuroglia, the vessels, and the connective tissue.

In order to interpret in a satisfactory manner the topography of tabetic sclerosis, we must not only examine the different regions of the cord in the same case, but also compare preparations coming from other cases, which may be different in their evolution or symptomatology. This done, we can then compare the lesions we find with those that are observed in the spinal cord after alteration of the posterior roots, whether these be experimental or pathological in nature.

Here are preparations from three cases of tabes (locomotor ataxia) who died in our service. In the first case there was a tabes which commenced in the dorso-lumbar region and later reached the cervical region. That is the usual form. The second case was a cervical one, in which the symptoms-pain, incoördination, and troubles of sensibility-affected the superior members mostly. The inferior members

were normal. The preparations of the third case come from a patient who, following a papillary atrophy at the onset, never had any further evolution of the disease. After fourteen years of fulgurating pains in his legs, he had no trace of incoördination.

These are the three usual types of tabes: the first, or ordinary type; the second, or cervical; and the third, that remains in the preataxic stage, the spinal lesion not advancing.

What is the state of the spinal cord in these cases?

In the first, or ordinary case, you will find, about the level of the lumbar region, that Burdach's and Goll's columns are entirely sclerosed. About the level of the dorsal region the lesions remain nearly the same, but at the inferior portion of the cervical region you will find

that the aspect is changing, and this continues as you go higher. Though the columns of Goll are invaded completely here, Burdach's columns are not, for in them the lesion diminishes as we ascend the cord.

The atrophy of the posterior roots follows the same course, and they show less change as we ascend the cord. Here are preparations of the cord in cervical ataxia (or tabes). Throughout the cervical region and the superior dorsal region the nervous fibres have completely disappeared in Burdach's columns, but they begin again about the level of the sixth dorsal pair. From here the lesion diminishes from above downward, so that at the lumbar swelling the lesion is hardly seen. As to the columns of Goll, in the cervical region they are altered only in the anterior two-thirds, while the posterior third is normal. These

alterations diminish so that at the lower lumbar region they can be considered normal. The posterior roots undergo the same change as Burdach's columns; that is, they diminish progressively from above downward, as to the alteration, and become almost, if not quite, normal in the lumbar region. It is only after staining the sections with osmic acid that we can find a very few fibres atrophied.

Let us now examine the third case, in which the tabes had remained for fourteen years in a preataxic state with blindness. In the lumbar region the sclerosis occupies Burdach's columns, Lissauer's zone, and the radicular zone, while Goll's columns are attached in their anterior two-thirds only. On the contrary, in the cervical region, Goll's columns are attacked with sclerosis in their posterior two-thirds only, while Burdach's fibres are normal.

Here, again, the alterations of the posterior roots are proportional to those of the rest of the cord. They are well seen in the dorsal and lumbar regions and absent in the cervical region.

We have, then, three cases of tabes in which the lesion presents itself with a topography somewhat different in each case. In the first, or ordinary tabes, the columns of Goll are as much sclerosed in the cervical region as in the dorsal and lumbar regions, while the sclerosis of Burdach's fibres diminishes from below upward in the cervical region. In the second case, cervical tabes, the lesion diminishes from above downward. In the third case, tabes arrested by blindness, Burdach's columns are altered only in the dorso-lumbar region, while the columns of Goll are less affected, and yet they are completely sclerosed in the two-thirds of the posterior cervical region. One single feature they have in common: that is, the alterations of the posterior roots follow the other alterations.

How shall we interpret this different topography? Is ataxia a systemic and primitive sclerosis of the posterior cord, as Charcot and Strümpell admitted, and as Füchsig and Raymond held?

To answer this question we must go into the history of the posterior cornu or horn in the sclerosis of tabes. Bourdon and Luys (1861) first described the pathological anatomy of Duchenne's malady, and for a long time we had no better description. In 1872 appeared Pierret's work, based on a study of the spinal cord in tabes. He showed that ordinary ataxia commences in the external bands of the posterior cornu. These have since been called Burdach's columns. The isolated sclerosis of the columns of Goll in the cervical region, observed in these cases, was seen only when the sclerosis of the lumbar region was very pronounced in character. This sclerosis of the columns of Goll, says