from the point of view of an exploration, possibly of great benefit, and almost certainly not of very serious consequences, inasmuch as the measure is only employed in the last stages. *NOTE BY DR. W. W. KEEN: The bulging of the brain after opening the dura was so great that had tapping not been done, it would have been impossible to readjust the flap of scalp so completely as to bring the edges of skin together, and the same hernia would have followed. At the same time we should have had no knowledge of the reason for the increased intra-cranial pressure, and there would have been no relief to the intense and agonizing headache. The relief to this last symptom at once, and the comfort it afforded the patient, was of itself a sufficient reason, in my opinion, to justify the tapping. * Dr. Keen was present at the operation but was unable to attend the discussion. TREMOR SIMULATING MULTIPLE CEREBRO-SPINAL SCLEROSIS, BUT WITHOUT COARSE CENTRAL LESION. BY F. X. DERCUM, M.D. The following case is reported because of the presence of a persistent tremor which always presented the same features, and because of the result of the autopsy. A. B., a mulatto, aged fifty-five years, male, was admitted to the medical wards of the hospital September 22, 1888. No family history was elicited, except that his sister had died quite suddenly of apoplexy. His statements regarding himself were equally meagre. He said that seven years ago after drinking a large quantity of cold water, he had had "rheumatism and diabetes." Shortly after this his left leg and arm began to tremble, and sometime later the trembling spread to the right arm and leg. He had never had apoplectiform attacks, nor could a history of any other previous illness be obtained. He complained of thirst and epigastric pain, but evidently these symptoms were not marked. A physical examination resulted negatively. The heart was normal. There was nowhere oedema. Repeated examination of the urine failed to disclose the presence of either sugar or albumen, nor any change in specific gravity. The tremor was coarse and became much exaggerated upon voluntary movement. The gait was somewhat spastic, and because of the tremor, very difficult. According to his own statements he was gradually getting worse. Alcoholism and syphilis were persistently denied. He was transferred to the nervous wards October 9. Here it was noted that the tremor involved the hands, the tongue, the face, and to some extent the legs. It was most marked upon the left side. It was again observed to be markedly increased during voluntary movement, to cease almost altogether when the patient lay down, and further, to cease absolutely during sleep. The knee-jerks were much exaggerated, especially the left, and ankle clonus could be elicited on both sides. Nowhere could any loss of sensation be detected. The man seemed at times a little slow in answering questions, and sometimes his answers were conflicting, but no delusions or other mental symptoms existed. Later on, however, decided mental deterioration became evident. Tremor of the mouth became very marked during attempts at speaking, so that speech was frequently interrupted, slow and retarded. The eyelids drooped and were tremulous. The pupils were now observed to be fixed and slightly unequal, the right being the larger and somewhat irregular in outline. Nystagmus was also present, and there was in addition, coarse tremor of the head. There was some diminution of the grip of the left hand, the grip being very tremulous and the object grasped seemed to be with difficulty let loose. He gradually grew weaker, and was finally compelled to remain in bed. Some hyperæsthesia now made its appearance upon the right side. The knee-jerks, however, from having been much increased, became normal on the right side and diminished upon the left. There was also noted a tendency to contracture at the knees, but this was not persistent. As he lay in bed, there was continual coarse, irregular tremor of the left hand and arm, almost chronic in character, and which became as before greatly increased on voluntary movement. The right arm was free from movement during rest, but voluntary effort induced tremors. Decided demen-* tia now set in. He spoke with increasing difficulty. During the last few weeks of his illness he lost control of the sphincters. The tremor, however, persisted, especially upon the left side, and became more pronounced upon attempts at examination and manipulation. A note made August 16, 1889, states that the patient lay apparently asleep with legs drawn up. The left eye was not entirely closed. The pulse was of moderate volume and tension, regular and not rapid. On attempting to feel the pulse, the patient appeared to rouse up and tremor made its appearance in the arms and hands. After a minute or two the movements ceased and the patient relapsed into his former quiet condition, the eyes, however, remaining open and the breathing hoarse and rattling. The patient died August 18, 1889. The temperature during the three days preceding, ranged persistently close to 103°, the pulse scarcely deviating from the normal, while respiration was slightly increased in frequency. During the last two days of life swallowing became difficult and ultimately impossible. The rectum was not retentive, and he was several times given milk and whiskey through a flexible catheter introduced into the œsophagus. Autopsy--August 19. Body of a well-nourished colored man with no special external peculiarities. Cord. - Dura normal. Pia and arachnoid normal, but vessels unusally prominent. On section cord seemed softer than normal. Brain.-Dura normal. Pia-arachnoid thickened, opague and oedematous; not adherent. The vessels full and dilated, and at the base distinctly atheromatous. The lateral ventricles were much dilated and their walls congested, the vessels containing dark and fluid-blood. On section of brain no areas of softening or induration are seen; no evidences of hemorrhage or other gross lesion apparent. pale and oedematous. Cortex The general post-mortem revealed little of interest. The left pleura was obliterated by old adhesions. Hypostatic congestion of both lungs. The heart was dilated and its muscles somewhat softened. The aorta and larger vessels were atheromatous. The liver and spleen presented nothing worthy of note. The kidneys, however, presented evidences of chronic interstitial nephritis. The brain and cord were carefully hardened in Müller's fluid, and sections were prepared according to Weigert's method by Dr. Hatch, one of the assistant pathologists to the institution. A careful study of these sections, which included all of the regions of the cord, the medulla, the pons, the crura, the basal-ganglia and capsules failed utterly to reveal any areas of sclerosis. The portions of the cortex preserved for examination were unfortunately lost, and it is not improbable that changes— not sclerotic however, but simply degenerative in character-might have been found here. Degenerative changes, however, were not apparent elsewhere. This obscure case is exceedingly instructive, showing how dangerous it is to rely upon the presence or prominence of a single symptom for diagnosis. The tremor was excessively misleading. It was the earliest, most constant and most prominent factor in the case, and at the same time its features were unvarying. The apoplectiform attacks so frequent in the history of multiple cerebro-spinal sclerosis were wanting, it is true, but as is well known they are occasionally absent. In looking over this case, however, and giving full weight to the progressive and rapid mental deterioration, the fixation and inequality of the pupils and the progressive muscular weakness, it becomes very probable that the patient before us was really a case of paretic dementia in which neither the mental symptoms were typical nor the speech characteristic, and in which for some reason, the tremor became an unusually marked and fixed factor. This case further gives rise to the suspicion that other cases reported as simulating multiple cerebro-spinal sclerosis, and yet presenting no lesion, find a similar explanation. THREE INTERESTING SPINAL CASES. Ι.—ΑΤΑΧΙΑ WITH PROGRESSIVE MUSCULAR ATROPHY. II.—ATAXIA WITH HEMIANÆSTHESIA. BY WHARTON SINKLER, M.D. FROM NOTES BY T. J. HARRIS, M.D. The first is a case of tabes in which there is an unusal degree of muscular atrophy. According to the patient's statement, the atrophy came on quite suddenly, about four years after he had had symptoms of ataxia. As to the abruptness of the onset of the atrophy he is no doubt mistaken, but it certainly is a fact that after the attack of vertigo of which he speaks, the atrophy progressed rapidly. Muscular atrophy affecting one limb, as we all know, is not unusual in ataxia, but it is rare to see all the muscles of the body affected as in this patient. CASE I.-J. P., Irish, laborer, aged fifty-three; his family history is negative. He came to this country at the age of sixteen. In Ireland he had measles, scarlet fever and small pox, and at seventeen had pleurisy. He has worked hard all his life. There is no history of alcoholism or venereal disease. For some years he has worked in the gas works, where he was exposed to much wet and dampness. Five years ago, when otherwise well, the patient began to have severe pains in his epigastrum; during these attacks he felt as if he would smother. These continued for a year, when he began to have pains in his knees and legs of a piercing nature. five months later he noticed that he could not walk as well as formerly. grew progressively worse until last January. Since then he has only been able to walk with the greatest difficulty, and with the aid of a cane. Four or His gait Last January he had an attack of vertigo, after which he noticed there was a considerable loss of power in both hands. At that time his hands began to waste simultaneously, and his feet began to feel numb. At the end of eleven months he became quite helpless. His condition at present is as follows: He walks with great difficulty, his legs widely straddled, his knees bent, his feet raised but a short distance from the ground. |