well of Brownstown died June 1.-Dr. Hughey of Chillicothe has removed to Washington C. H.-Dr. J. S. Rose of Dayton died recently.-Dr. A. Hurd of Findley recently married Miss H. E. Wendell.

PENNSYLVANIA.-Dr. D. Gumpert of Wilkesbarre died June 17.-Dr. T. S. Weller of Meyersdale died suddenly.-Dr. J. M. Peralta has located in Lancaster.-Pittsburg-Dr. E. A. Wood died June 4.-Dr. Weaver of Wilkesbarre reports a case in which a boy with an extensive skull fracture walked for two hours without noticing it.-The new graduates are legally refused registration without re-examination.-Dr. I. W. Hays of Allegheny died recently.-Dr. M. F. Phillippi of Reynoldsville died June 6.

RHODE ISLAND.-Dr. E. T. Kelly of Providence died June 6, and Dr. C. Hayes June 8.

SOUTH CAROLINA.-Charleston-Dr. James De Veaux married Miss F. Greeley June 7.-Dr. M. Michel died June 4.

TENNESSEE.—In a suit against a "Catarrh Cure" for non-payment of reward for non-cure the defense claimed it was a mere wager, but the Supreme Court held the contract valid.-Nashville-Dr. W. T. Briggs died June 17.-Dr. O. P. Lawrence of Knoxville died June 1.-Dr. A. Griffith of Chattanooga died recently.

TEXAS.-Dr. M. E. McGrath of San Antonio died recently.-Dr. Bragg of McDuff died June 2. VERMONT.-Dr. G. B. McGraw has located at Poultney.-Dr. A. N. Pearsons of Berlin Corner died recently.

WASHINGTON.-Drs. Mizner of Tacoma, Van Zant of Whatcom, and J. E. Bingham of Walla Walla have been appointed members of the state board of examiners.

WEST VIRGINIA.-Dr. W. S. Burdett of Huntington died recently.

WISCONSIN. Dr. T. Yuengst of Janesville died June 3.-Drs. H. M. Read, A. F. Heising and G. T. Finstad have been appointed pension examining board of surgeons for Dunn county to succeed Drs. Baker, Grannis, and Jackson.Milwaukee-Dr. Julia Ford died June 2.

ESSENTIALS OF PHARMACY.*-The present edition has been revised in accordance with the 1890 United States Pharmacopoeia. An outline of drug and plant analysis and other additions of interest and value are made to the present edition. The volume is of much reference value to the practitioner as well as the student, and in the full sense of the word is a handy volume.

THE GRAND RIVER (Mo.) MEDICAL SOCIETY met at Chilicothe, Mo., June 8. The following

officers were elected:

*Essentials of Practice of Pharmacy. Arranged in the form of Questions and Answers. Prepared especially for Pharmaceutical Students. By Lucius E. Sayre, Ph. G. Second Edition. Revised. 12mo., pp. 200. Philadelphia: W. B. Saunders. 1894. Price, $1.00. Chicago: W. Keener Co.

Drs. Robert Haley, president, Brookfield; W. B. Davis, Dawn, and B. B. Putnam, Bucklin, vice-presidents; E.S. Wenger, secretary, Brookfield; W. B. Scott, assistant secretary, Bucklin; R. Barney, railroad treasurer, Chillicothe.

THE CHICAGO MEDICO-LEGAL SOCIETY elected the following officers:

President, Dr. James Burry; first vice-president, Dr. C. D. Wescott; second vice president, Dr. Sanger Brown; secretary, Dr. Archibald Church; treasurer, Dr. Joseph Matteson.

THE SOUTH DAKOTA MEDICAL SOCIETY met at Huron June 20. President Peterman delivered the annual address. Papers were read as follows:

"Brain Tumor," Dr. Arthur Sweeny, St. Paul, Minn.; "Nervous Diseases," Dr. R. E. Buchanan, Independence, Ia.; "Lymphoid Tumors in the Vault of the Pharynx," Dr. H. Longstreet Taylor, St. Paul, Minn.; Address on Surgery, Dr. O. W. Phelps, Hawarden, Ia.; Address on Gynecology, Dr. R. T. Dott, Alexandria; Address on Hygiene, Dr. M. Ware, Topeka, Kan.; "Diseases Among the Sioux," Dr. Frederick Treon, Crow Creek, S. D.; Address on Obstetrics, Dr. W. J. Maytum, Alexandria; Address on Diphtheria, Dr. J. D. Herman, Conde, and Dr. Frederick Andros, Mitchell; "Penal Institutions,' Dr. I. R. Spooner, Lake Preston; "Keeley Cure," Dr. R. D. Melvin, Parker; Dr. Francis E. Kyle, Sioux Falls; Dr. W. H. Lloyd, Salem; Abdominal Surgery, Dr. J. Q. Adams, Scotland.

Officers for the ensuing year are: R. T. Dott of Alexandria, president; G. E. Martin of Parker, and Dr. Edwards of Bowdle, vice-presidents; W. J. Mayton of Alexandria, secretary; Earl Rice of Desmet, treasurer,

THE University of Pennsylvania Medical Department graduated a class of 207.

THE New York College of Physicians and Surgeons graduated a class of 120.

THE Hospital College of Medicine graduated a class of 130.

THE Syracuse New York University Medical Department graduated a class of 9.

THE Missionary (N. Y.) Medical College graduated a class of 10.

RUSH Medical College graduated a class of 163.

THE St. Louis American Medical College graduated a class of 25.

THE Northwestern University Medical Department graduated a class of 70, and the Woman's Medical College a class of 30.

THE Cincinnati Eclectic College graduated a class of 17.

THE New York Infirmary Woman's Medical College graduated a class of 17.

Epilepsy following on the various forms of infantile encephalitis exhibits in my experience many peculiarities.

It is more apt to be accompanied by trophic phenomena of the extremities varying from the simple "dead fingers" to phenomena nearly approximating Reynaud's disease. It reacts badly to the bromides. Mental symptoms, fits of temper, of sullenness, of depression, or even destructiveness, replace, under the bromides, the convulsive attacks. The tendency to impairment of the circulatory innervation of the extremities is increased. The various bromide dermatoses appear with comparatively great frequency. In not a few instances, these eruptions have proven unduly severe and protracted. A nocturnal mental type takes the place often of the convulsions. It is attended by phenomena closely resembling those of somnambulism. In some few instance an intense pruritus results While the dermic phenomena due to the bromides yield to arsenic, calcium sulphide, etc., still these ameliorations are very temporary and the original phenomena recur after a time.

As Spitzka has pointed out,* epilepsy is a diseased state of the encephalon, without a palpable characteristic lesion, and manifesting itself in explosive activity of an unduly irritable vaso-motor centre, leading to complete or partial loss of consciousness, which may be preceded or followed by various phenomena, expressing the undue preponderance of some, and the suspended inhibitory influence of other cerebral districts. The patho-anatomical changes found in patients suffering from the disease under consideration, throw but little light on pathological physiology. Certain vascular phenomena accompany an epileptic attack so constantly that they have been considered the fundamental essential factor of epilepsy. Suddenly produced anæmia of the higher nerve centers will, it is true, produce convulsions. But

*MEDICAL STANDARD Vol. 1.

it does not follow that the arterial spsasm is the direct cause of the epileptic fit. The convulsion, while a phenomena of the fit, is neither an initial nor an early phenomenon, nor is it as constant as it should be were the Kussmaul-Tenner theory

correct.

Nor does the discharging lesion theory of Hughling-Jackson fully explain the phenomena of epilepsy. That an irritative lesion of different portions of the brain can result in epileptiform explosions, is no proof that the idiopathic epileptic attack has a similar origin and in similarly located foci of impalpable disease. Take an inflammatory softening in or near the cortical area, which stands in a relation to the muscles of the arm; epileptiform spasms may be a symptom of such a lesion, and they may begin in the particular muscles whose "center" is affected, they may then extend to the other muscles of that half of the body, or suddenly to the entire voluntary muscular system. Is that proof that the epileptic "discharge has extended through the cortex by irradiations?" It does not seem that this could be maintained in cases where the transition from the localized, or, as it were, "focal" spasm to the general convulsion was sudden. It seems more probable that the primary irritation had determined a secondary irritability of the great convulsive center of the body, namely, the reticular gray matter of the brain isthmus, particularly of the pons and medulla. Starting with the fact that all the characteristic features of the full epileptic onset can be produced in animals deprived of their cerebral hemispheres, a satisfactory theoretical view of the nature of epilepsy will be arrived at. It needs but a slight puncture with a thin needle to produce typical convulsions in the rabbit and some of the convulsive movements reported by Nothnagel have not only shown the true epileptic character, but, also, that peculiar automatism noted in aberrant attacks. It is in this segment of the nervous system that

all the great nerve strands conveying motor impulses both of a voluntary and automatic, and some of a reflex character, are found united, in a relatively small area, and just here a relatively slight disturbance might produce functional disturbances, involving the entire bodily periphery.

The experiments of physiologists have shown that if a sensory irritation of a given spinal nucleus is kept up after having produced a reflex movement in the same segment, if there is any reaction beyond the plane of that segment at all, it is not in the next or succeeding planes, but in the medulla oblongata. The motor reaction then manifests itself in laughing, crying, or deglutitory spasms, and if the irritation is of the severest kind, epileptic or tetanic spasms in addition. Now the occurrence of laughing, crying, or deglutitory spasms could be easily understood if the molecular oscillation induced by the irritation were to travel along the associating tracts from the given spinal segment to the nuclei of the medulla oblongata. For in the medulla there are found the nerve nuclei which preside over the facial, laryngeal and pharyngeal muscles. It is not easy to understand how tetanus and epilepsy, that is spasms consisting in movements whose direct projection is not in the medulla oblongata, but in the cord, are produced by irritation of the former.

There are scattered groups of nerve cells in the medulla oblongata which have either no demonstrable connection with the nerve nuclei or are positively known to be connected with the longitudinal associating strands. These cells, hence, can safely be regarded as representing a presiding centre over the entire spinal system. No spinal centre exerts any influence even remotely as pronounced as that of the medulla oblongata on the entire cord. This applies to man and other mammals. That the elaboration of the medullary centre was as gradual a process as that of other higher differentiations is illustrated by the case of the frog, whose medulla has acquired the faculty of reproducing general spasms, while the spinal cord itself retains this property also; hence here the predominance of the medulla is not so marked as in the mammals.

The reticular ganglion of the oblongata is not, in the adult, a part of the central tubular gray matter, but has, though originally developing from it in the embryo, become ultimately isolated from its mother bed. It constitutes a

second ganglionic category and the association fibres bringing it in functional union with the spinal gray (first category) in lower animals and shown to have assumed the position of projection fibres in the higher constitute a second projection tract; both together are a second projection system. The scattered gray matter of the medulla has an (inferentially) great importance. Anatomically, it is (though its cells be scattered diffusely, as a rule), a large ganglion with numerous multipolar cells of all sizes; many of them of gigantic size, sometimes exceeding the so-called motor cells (which they simulate in shape) of the lumbar enlargement in size.

Scattered in the "reticular substance" of the medulla from the upper end of the fourth ventricle to the pyramidal decussation they merit collective designations of reticular ganglia.

The cells of the reticular formation are known to be connected with the nerve nuclei on the one hand, and with longitudinal fasciculi, which, since they run into the cord, terminate either in the gray matter (or the nerve roots directly), for nerve fibres do not terminate with, as it were, blind ends. Now, in the mammalian brain the reticular ganglion lies scattered among fibres which come from higher centers, and the interpellation might be made whether, after all, the reticular ganglion is not a mere intercalar station for fibres derived from a higher source. That originally the ganglion was an independent station, there can be no reasonable doubt, for in reptiles this body of cells is too considerable to account for a termination in them of the few cerebral fibres possessed by these animals. And, on the other hand, the vertical strands are notably increased in their passage through the field of the medulla oblongata.

The medulla oblongata, with its reticular ganglion, seems to be the great rhythmical center. In fish, the movements of the operculum and mouth; in sharks, those of the spiraculum; in perenni-branchiate amphibians, the branchial tree; in the infant, the suctorial muscles; in all vertebrates, the movements of deglutition, of the heart and respiratory muscles; all movements presenting a more or less regular rhythm are under the control of the medulla oblongata. The early differentiation of this part of the cerebro-spinal axis is, without doubt, related to the early manifestation of rhythmical movements in the embryo, and their predominant importance in lower animals. The possibility should not be excluded that a rhythmic

movement may be spinal, nay, even controlled by peripheral ganglia (heart of embryo). A higher development, however, implies the concentration of rhythmic enervations at some point where that anatomical association may be effected which is the expression of the mutual influence these movements exercise among themselves.

Two sets of phenomena need be borne in mind in studying the physiological pathology of the epileptic attack. First, the condition of the epileptic in the interval. Second, the explosion itself. Too much attention is paid to the last, too little attention to the first. The constitutional epileptic is characterized by a general deficiency of tonus, associated with exaggerated reaction and irritability. Thus the pupils are at once widely dilated and unusually mobile. The muscular system, though generally relaxed, manifests exaggerated reflex excitability. The mental state is characterized at once by great indifference and undue irascibility. In the same way the vascular system is depressed in tone in the interval, with rapid marked changes under excitation. The state of nervous system as a whole is comparable to that of an elastic band which, being on the stretch continually, is apt to overshoot its mark when one end is let go. Under normal circumstances the band is less stretched, and hence not as liable to fly so far when the check is removed.

An irritation which in health produces restlessness of the muscular system, accelerated respiration and pulsation, and various mental phenomena within the normal limits, in the epileptic results in more intense phenomena in the same direction. The nervous irritability of the epileptic manifests itself in one direction especially.

An important vaso-motor center for the brain-vessels exists, possibly diffused through an area somewhere between the thalamus and subthalamic region above, and the pyramidal decussation below. The irritability of this center results in the sudden arterial spasm in the carotid distribution; so characteristic a feature of the fit onset simultaneously with the contraction of the vessels, the pupil undergoes an initial contraction, and relaxation instantly results in both cases. The sudden interference with the brain circulation produces unconsciousness, and destroys the checking influence of the higher centers on the reflexes in a manner analogous to any shock affecting the nerve centres. In the meantime, while there has been as sudden a deprivation of arterial blood and a sinking of in

35

tracranial pressure so far as the great cerebral masses are concerned, there has been as sudden an influx of blood to the unaffected district of the vertebral arteries, whose irrigation territory is now the seat of an arterial hyperæmia, The result of this is that the great convulsion centre,* the medulla, being overnourished, functional excess, that is convulsion, occurs, unchecked by the cerebral hemispheres, which are disabled by their nutritive shock. The impeded return circulation of venous blood now comes into play. The contraction of the neck muscles explains this obstruction, and the accumulation of venous blood in the cerebral capillaries of the medulla especially. especially. Meynert is of opinion that this venous blood, by the formation of cyanide-like substances, acts as a toxic agent, and produces the severer symptoms noted during the post convulsive period, recently supported by the finding of urine toxins by Féré.

In addition to those sustaining the "rubber band" analogy, the following facts tend to demonstrate the view just expressed: First (a), the contraction of the retinal artery; (b), the initial and very brief contraction of the ordinarily dilated pupils; (c), the sudden pallor of the countenance. Second (a), the secondary expansion of the retinal arteries; (b), the secondary dilation of the pupils; (c), the secondary flushing of the face. Third, the post-mortem appearances found in those dying immediately after severe convulsive seizures.

True epilepsy presents an enormous number of sub-groups, exhibiting every variety of deviation from the ideal convulsive form, and the existence of these forms tends to demonstrate the views just expressed. In ordinary petit-mal the initial arterial spasm has but to be confined to the surface of the hemispheres, leaving the thalamus ganglia undisturbed, and it can readily be understood how the momentary unconsciousness or abolition of cortical function can occur without the patient falling, his automatic ganglia still carrying on their functions. At the same time, with the lesser spasm there would be a less extensive sinking of intracranial pressure, and less consecutive collateral hyperæmia of the lower centres, and therefore no convulsion.

As Meynert has suggested, in certain cases the arterial spasm may fail to affect the entire cortical surface simultaneously; some one trunk

*The unconsciousness and coma of epilepsy more resemble shock than they do cerebral anæmia or syncope.

+It can now readily be understood why vertebral arterial ligation fails permanently to relieve epilepsy.

may be more previous and an afflux of blood may occur in its special field where certain impressions and motor innervations are stored; the result will then be that the function of the relatively well-nourished territory will be exalted. If it be a visual-perception territory, sights, colors, or luminous spectra will be seen; if it be an olfactory territory, odors will be smelt; if a tactile center, crawling, tingling, and cold sensation; if a speech center, cries, phrases, and songs may be observed. This explains the manifold epileptic aura which is simply an isotated exaggerated limited cortical function. The recurrence of the aura is readily explicable on the ground of the well-known physiological law that any nervous process, morbid or normal, having run through certain paths, those paths will be the paths of least resistance for that process to follow in the future. To an extension of the same condition are due the peculiar convulsive equivalent and post-epileptic mental

states.

Encephalitic epilepsy, while in many cases possibly Jacksonian at the outset, but too often becomes an epileptic constitution with all the phenomena of idiopathic epilepsy underlaid by the pathology just enunciated. In the treatment of these states, where the disagreeable effects of the bromides are observed, this pathology becomes of importance in therapeusis.

A little less than two decades ago nitroglycerin, acting on the morbid phenomena described, was introduced on therapeutical grounds without reference to bromide untoward effects. It was found by neurologists that it had neither the tendency to produce mental symptoms by suppression of the epileptic discharge, nor yet the distressing dermic phenomena of encephalitis. Spitzka found it of especial value given at shorter intervals than the bromides in 50-grain doses. Trussewitch points out that it should be used when there is a defect in the equilibrium of the vascular tone, and the blood is irregularly distributed. It causes a rush of blood to the anæmic district or unloads the hyperæmic. He finds, as did Spitzka, that after a time there comes a toleration of the drug. It should then be dropped for one or two weeks, when susceptibility will be regained. Osler finds that the physiological effects must be apparent before good effects are obtainable. It controls, given on the principles indicated, the restlessness, the temper as well as the motor phenomena of *Sajous Annual, Vol. IV, 1888, p. 487.

these epileptics. It is best given eight times* daily in grain doses. The gastro-intestinal system should, of course, be carefully looked after; the skin circulation kept in good shape by proper bathing, and excess in meat diet avoided. The best effects are thus obtained.

SALOPHEN IN ACUTE RHEUMATISM.-Continued clinical experiments have shown that salophen exerts a specific influence in acute articular rheumatism, and deserves a preference over salol and the salicylates because possessed of all the advantages and devoid of the disadvantages of these remedies. Salophen does not irritate the stomach, weaken the heart, or produce the unpleasant nervous phenomena which so frequently result from the salicylates, while in promptness and certainty it is fully equal to the latter. The following case reported by Dr. Holzschneider of Cronenberg illustrates the action of salophen in acute rheumatic affections. A thirty-six year-old man was attacked by a severe articular rheumatism involving all the joints and following several light attacks of influenza. The joints were swollen, red and painful, the pain being especially violent in the shoulder, wrist and ankle joints. A course of treatment with soda salicylate was instituted, but in spite of the small size of the doses the patient suffered from marked prostration, ringing in the ears, headache, vertigo, epistaxis, and especially serious gastric disturbance and bilious vomiting. Owing to the irritating effects of the salicylates the patient had to be confined to a diet of milk and wine for fourteen days, and as he refused to continue this remedy, Dr. Holzschneider was limited to the employment of massage and topical applications. Having had his attention directed to salophen, he administered it in 1.0 gm. doses three or four times a day, and under its use observed rapid diminution of the pain and swelling of the joints, and improvement in the general condition of the patient. There were no unpleasant after-effects and the digestion was not impaired. It is noteworthy that considerable improvement ensued after the first 4.0 gm. of salophen. The powder was taken dry on the tongue and followed by a swallow of water. The patient was well wrapped in woolen blankets and given abundant quantities of peppermint and elder tea. Every dose was followed promptly by perspiration and a general feeling of comfort.

*The 1-250 gr. granules of Dr. W. C. Abbott are excellent for this purpose.