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we think that Mr. Hutchinson's desire for reducing the phenomena of syphilis into an orderly correspondence with those of the specific fevers has carried him into error, and that his arguments for placing the tertiary symptoms outside the period of blood-disease entirely fail. In the first place, as Sir William Jenner pointed out, blood-diseases do not display by any means a constant symmetry in their manifestations, e. g. the eruption of typhoid fever is particularly unsymmetrical; again, as Dr. Moxon showed, some of the most striking manifestations of symmetry are seen in tertiary syphilis, and he instances the familiar occurrence of symmetrical tertiary ulcers, and also cases of symmetrical cerebral gummata. Many of the secondary symptoms, again, are not at all symmetrical, and some purely local affections are so. Mr. Lee has also alluded to the fact, mentioned by Mr. Hutchinson, that gummata may be found in the liver at the same time that there is a secondary eruption upon the skin, and it is difficult to imagine the eruption to be a manifestation of the blood-disease, and the gummata to be due to something else. The most important distinction between the different manifestations of constitutional syphilis is that laid down by Mr. Lee with regard to its treatment:

"At whatever period of the disease we find the existence of the specific adhesive form of action, whether developing itself as a primary manifestation in the shape of an indurated sore, or as an affection of the inguinal glands, or in the form of papular, tubercular, or scaly eruptions on the body, mercury is, in my opinion, sure, if properly administered, to be beneficial. When the disease, whether primary, secondary, or tertiary, has a tendency to produce suppuration in the affected parts, mercury should be administered with great caution."

There is but little difference of opinion now about the value of mercury in the treatment of syphilis, but there is still considerable variety in the mode of its administration. Mr. Lee calls attention to the practice of Pearson, who had immense experience in the mercurial treatment of syphilis, and who, as well as Sir Benjamin Brodie, who followed him, preferred to all other methods, that of inunction. A still better plan is that of the calomel vapour bath, administered according to the plan introduced by Mr. Lee. In this way the curative effects of the drug are obtained without any of the evils which pertain to other methods of administration, and the dose and action can be regulated with the greatest nicety. The value of the iodide and bromide of potassium consists rather in the removal of symptoms, than in the cure of the disease, and sarsaparilla is chiefly of value in the treatment of the bone affections.

In considering the doctrines of Hunter with regard to syphilis,

it is interesting to observe how the most recent investigations into the subject have confirmed many of his most important observations, and to note also how the philosophical general principles at which he had so laboriously arrived, preserved him from the errors into which some of his successors have fallen, and enabled him to anticipate some facts which have only recently been clearly established. As Mr. Lee says, "Some of his doctrines require to be modified by the light of more recent investigations; while others, which have been long neglected, will still serve as landmarks for this and for succeeding generations." It is pleasant to see a Hunterian professor treating his subject in so truly Hunterian a method as Mr. Lee has in these lectures displayed.

IV.-Bulbar Paralysis.

THE energy and activity that have been manifested within the last few years in the department of neuro-pathology have brought about many additions to the nomenclature of diseases of the nervous system, additions not always permanent, and not seldom having to give way to others possessing more definite attributes.

Until within a comparatively recent period the medulla oblongata, although the seat of the nuclei of the nerves essential to the performance of the functions of animal life, has not been the object of pathological research in any degree commensurate with the importance of its complex anatomical and physiological relations, or proportionately with the pains that have been bestowed upon other portions of the nervous centres. M. Claude Bernard was one of the earliest to direct attention to the pathology of the medulla oblongata, through his experimental researches upon the production of polyuria and glycosuria in connection with lesions of the fourth ventricle.

Trousseau in 18411 wrote a memoir founded upon a case of paralysis that came under his notice at that time. Twenty years later the same distinguished observer recognised in this case the disease which Duchenne had then traced to its true pathology and described as glosso-labio-laryngeal paralysis in the Archives Générales de Médecine.' In the mean time M. Duménil had, by aid of the microscope, discovered a morbid condition of

1 Lectures on Clinical Medicine,' by Trousseau, translated by Victor Bazire, M.D. London, 1867.

the nerve-roots in a complicated case of paralysis of the tongue and progressive muscular atrophy. M. Trousseau in several fatal cases observed atrophy of the roots of bulbar nerves and increased consistency of the medulla oblonga from increase of the connective tissue of the dura mater. We shall see that subsequent microscopical investigation has pointed out the special structures which in the medulla oblongata present the morbid appearances now usually associated with this form of disease.

M. Duchenne, to whom we owe the name 66 "glosso-labiolaryngeal paralysis," traced further the atrophy of nerve-roots described by Trousseau, Duménil and Wilks, to atrophic degeneration of the nerve-cells of the nuclei of the hypoglossal, vagus, facial and trigeminal nerves. The close connection or grouping that exists among these nuclei has been demonstrated by Dr. Lockhart Clarke. Later researches by Charcot, Jaccoud, and others, have confirmed the observations of Dr. Duchenne. Dr. Dowse adopts the epithet "bulbar" as the more scientific, since, while glosso-labio-laryngeal certainly expresses the prominent symptoms, it leaves out of view the seat of lesion of the nervous centre.

The degeneration of the nerve-cells of the bulbar nuclei consists in alteration of their forms, and the diminution of their sizes, even to their fading into merest traces of their former characteristics. Those cells which have not advanced so far in the process of disintegration present to low powers of the microscope the appearance of black specks. These, when further resolved by higher powers, are found to consist of cells which have lost their normal translucent characters, and are more or less filled with dark opaque granules, the nucleus being lost among these, or having become broken up into the same granular material. The surrounding neuroglia and medullary substance have also suffered a change, having become converted in some instances into forms of sclerosis, miliary, insular or disseminated, from increase or degeneration of the connective elements-patches of Clarke's "granular degeneration."

The characters of insular sclerosis as seen in the brain are thus described by Dr. Moxon ; the description applies to the same lesion in the medulla or cord.

"It appears in the form of circumscribed patches, generally circular on section when small, but growing more irregular as they enlarge to the size of a hazel-nut or larger. They have very much the appearance of grey cerebral matter, but are tough and firm, the whole brain being also much firmer than natural. When small

14 Lectures on Pathological Anatomy,' Wilks and Moxon, 2nd edit., p. 230, 1875.

and circular they often appear to surround a congested vessel, but as they grow larger this is not evident; the vessels in the mare, however, always rather large and full of blood. They appear to us to arise at small points and spread excentrically like an eruption; when small they have a dark grey colour; as they enlarge they grow paler, until at last they are with difficulty distinguished from the surrounding structure, but they have a light ochrey opacity and slightly curdy appearance, different from the creamy pink tint of healthy brain. They very seldom invade the grey matter; when they do the cells of the grey matter persist longer than the white fibres. By the microscope you will find that the nervous elements are greatly wasted away, a quantity of subfibrillar hyaline material is present, in which are countless granule-masses, and often also a variable number of amyloid corpuscles."

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A portion of brain or spinal cord that has undergone sclerosis is readily detected, even by the naked eye, when carmine or other dyes have been used in the preparation of thin sections. A section thus prepared will exhibit the sclerosed tracts distinctly marked out, the healthy portions presenting their translucency and clearly showing the myeline and axis cylinders of the divided nerve-fibres, while the morbid tract has, under a low power of the microscope, a generally confused and partially opaque aspect. On submitting this portion to the scrutiny of the higher powers, e.g. a quarter or eighth of an inch objective, the section will exhibit instead of the cut ends of nervefibres with tinted axis cylinder and surrounding uncoloured transparent sheath of myelin, an irregular network of connective tissue, intermingled with which are disintegrated or enlarged connective nuclei, fragments of myelin, and deposits of miliary degeneration. In the so-called "medullary rays,' which are but the normal septa of areolar tissue binding together the longitudinal bundles of white fibres of the medulla, we find the traces of dilated and wasted vessels and broken-up nuclei of the neuroglia. The original radiating septa have disappeared from the sclerosed parts, which in the untinted cord present generally a lighter colour than adjacent healthy substance. In a recent, unhardened section the sclerosed substance shows frequently fat or oil-globules surrounding the remains of the wasted vessels of the cord. The essential element of sclerosis is thus seen to be hyperplasm of the connective tissue followed by atrophy of the other structures of these organs. Bulbar paralysis does not, however, always connect itself with sclerosis, although it inevitably follows the invasion, by this change, of the fourth ventricle and the nuclei of the nerves of the medulla oblongata. The forms in which this lesion presents itself in this centre are well represented by the woodcuts

accompanying M. Bourneville's edition of Charcot's lectures.1 It should not be overlooked that the condition most frequently arising out of insular sclerosis is that of muscular tremors as seen in paralysis agitans and allied affections. Softening and grey degeneration of the medulla, together with atrophy and pigmentation of cells of the bulbar nuclei, are also as frequently associated in bulbar paralysis.

M. Charcot, viewing the medulla oblongata as a continuation of the spinal cord, and having observed that cases of muscular atrophy are associated with atrophy or degeneration of the anterior cells of the cord, directed his researches to the condition of the hypoglossal nuclei, in a case of atrophy of the tongue, and has subsequently traced a similarity between the condition of the cord and the medulla in several other forms of disease.

Dr. Hallopeau,3 in his monograph, has collected the observations of other pathologists, adding thereto the results of his own investigations, and dividing the cases of bulbar paralysis into three groups-1, those arising from lesions of the nuclei or radial fibres; 2, lesions of the conducting fibres to the cerebral or spinal centres; 3, those arising from lesions of cerebral fibres connecting the cerebral ganglia with bulbar nuclei.

This division, the author urges, has not only a physiological interest, but has also a clinical value, inasmuch as these several groups present differences which should be recognised. Thus, in the first group the paralysis is on the same side as the lesion. In the second the reflex as well as the voluntary movements are affected. In the third group the paralysis is habitually associated with muscular atrophy. In the first and third groups the paralysis is limited to parts supplied by bulbar nerves; in the second the affection implicates also parts supplied by spinal nerves. Pathological facts, referable to this second division, show that the motor influence is not wholly transmitted by the decussating fibres of the pyramids. Dr. Brown-Séquard has drawn attention to this pathological fact by the record of cases of paralysis on the side of lesion in the brain.1 M. Vulpian relates a case of complete atrophy of one of the anterior pyramids in which no paralysis existed, and another in which the lower extremities only were affected. M. Hallopeau also gives a case (No. xxix) of lateral lesion of the medulla oblongata, attended by paralysis of the limbs on the same side, showing that a portion at least of the fibres do not

1 'Leçons sur les Maladies du Système Nerveux,' 3me fascicule. Paris, 1873. 2 Archives de Physiologie,' 1869.

Des Paralysies Bulbaires,' Paris, 1875.

'Lancet,' Jau. 1, 1876.

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