Nervous diseases: their description and treatment. A manual for students and practitioners of medicine

Front matter

A

-A

NERVOUS DISEASES:

Preface To The Second Edition

In pj-esentiiig a new edition of my book I wish to express to the profession my hearty appreciation of the favorable reception accorded to the first, which has been out of print for several months. I thank my impartial reviewers, and take pleasure in saying that wlierever possible, I have endeavored to adopt their suggestions, and I trust, have succeeded in remedying tlie faults, many of whicli are unavoidable in a first edition.

The present edition is enlarged by nearly one hundred pages and contains many new illustrations, in fact this feature of the book has undergone an almost entire change. The enlargement is a matter of necessity, omng to the recent advances in our knowledge of neurological medicine. I liave used certain portions of my essay which received the prize of the American Medical Association, in 1879, in the preparation of a chapter upon diseases of the lateral columns of the spinal cord. Other chapters have been remodeled, and I hope improved, especially in regard to the introduction of matter relative to localization of disease in the brain and spinal

<;ord.

ALLAN McLANE HAMILTON,

New York, 43 East 33d St.

Nov. 1st, 188L

Preface To The First Edition

It has been my object to produce a concise, practical book; and should the satisfaction be ever accorded me of knowing that I have made the subjects of Diagnosis and Treatment of ^N^ervous Diseases more simple to my readers than I think they now are, I shall be amply rewarded for the task I have undertaken.

I have not considered Insanity, because I believe that this subject deserves much more extended notice than it could possibly receive in a book of this size and kind.

I have deemed it advisable to include a short article upon Cerebrospinal Meningitis, though, by many authorities, it is not regarded, strictly speaking, as a nervous disease. I think, if for no other reason, its interesting diagnostic relations entitle it to consideration.

In conclusion, I wish to thank Drs. Loring, Janeway, Mason, Shakespeare, my resident physicians, Drs. JNIeyer, Xaylor, Ryan, and Baldwin, and Mr. F. O. C. Darley, for valuable assistance in the preparation of this volume.

• ALLAN McLANE HAMILTON.

Introduction

PAGB

I. Hints in regard to Methods of Examination and Study — Exammation of the patient, symptomatology, etc. — Autopsical and microscopical examinations . 17-21

II. Instruments used for the Diagnosis and Treatment of Nervous Diseases — The Thermometer, ^sthesiometer, Dynamometer, Ophthalmoscope, The Percussion hammer — Apparatus for the Treatment of Nervous Diseases — Electrical, Rubber Muscles, Hypodermic Syringe, Ether- Spray Apparatus, Spinal and Cranial Ice-bags, Cauteries, etc. . . 22-37

Chapter 1

diseases of the cerebral meninges.

Cerebral Pachymeningitis — Acute, chronic — Chronic Pachymeningitis with haematoma — Acute Cerebral Meningitis, basal, vertical — Rheumatic Meningitis — Meningitis of the Aged — Acute Granular (Tubercular) Meningitis — Acute granular meningitis of the convexity — Chronic Cerebral Meningitis 38-75

CHARTER II.

diseases of the cerebrum and cerebellum.

Symptomatic Cerebral Hypercemia — Cerebral Hemorrhage . . . 76-126

BULBAR DISEASES.

PAGE

Epilepsy — Bulbar Paralysis 384-420

Chapter XIV

. CEREBRO-SPINAL DISEASES.

Cerehro- Spinal Meningitis — Cerebro- Spinal Sclerosis — Alcoholism — acute — chronic — Nicotinism — Hydrophobia — Hysteria — Hystero-Epilepsy — Catalepsy . 421-482

CHAPTjER XV.

CEREBKO-SPIXAL DISEASES (CONCLUDED).

Chorea — Paralysis Agitans — Exophthalmic Goitre .... 483-510

DISEASES OF THE PERIPHERAL NERVES (CONTINUED).

Local Paralysis — Facial paralysis — Traumatic paralysis — Diphtheritic paralysis ............ 548-5G5

Chapter XIX. Diseases Of The Peripheral Nerves (concluded)

Lead Poisoning — Functional Spasm — Tetany — Functional spasm with voluntary movements: — Reflex spasm — Facial spasm without pain — Torticollis — Professional Cramp — Writer's Cramp — Dancer's Cramp — Telegrapher's Cramp, etc., etc. — (Esophagismiis . . . • . . . . 566-587

LIST OF ILLUSTRATIONS.

no. rAUK

1. Seguin's Surface Thermometer 22

2. Gray's System of Head Straps 23

3. SiSVEKING's iEsTHESIOMETER , 26

4. Diagram for making Records 28

5. Mathieu's Dynamometer , 2V»

6. The Author's Dynamometer 30

7. Loring's Ophthalmoscope 31

8. Percussion Hammer . , 33

9. Manner of Testing Tendon-reflex. (Goivers) 3i

10. The Author's Gas Cautery 36

11. Osteoma OF Dura Mater. (Lancereaux) 43

12. Tuberculous Matter about Vessels. {Corniland Banvier). ..... ^(i

13. Distended Perivascular Spaces. {Fothergill) 86

14. 15. Tracings of Patellar Tendon-Reflex. (Brissaud) 101

16. Cortical Centres. {Morel) - . 105

17. Charcot's Scheme of Cerebral Motor Tracts ; 107

18. Internal Cerebral Vascular Supply. {Charcot) 110

19. External Cerebral Vascular Supply. {Charcot) Ill

20. Miliary Aneurisms 113

21. Multiple Lesions with Tongue Atrophy • . . 117

22. Instrument for Applying Heat and Cold 126

23. Tissue Changes in Softening 175

24. Handwriting of Agraphic Patient. {Bourneville) . 184

25. Handwriting of Patient with Cerebro-Spinal Sclerosis and Agraphia 184

26. Plate Showing Third Frontal Convolution. {Bateman) 186

27. Choked Disk. {After Leibreich) 208

28. Plate Showing Decussation of Optic Nerve Fibres. {Charcot) . . . 209

29. Tubercular Deposit 212

30. Sarcoma of Brain 212

31. Gumma of Brain ; . . . 213

32. Psammoma of Brain 2l.')

33. Encephaloid of Brain 213

34. Glioma of Brain 213

34a. Cerebellar Aneurisms. {Bristowe) 229

35. Deformity of Hand in Cervical Pachymeningitis. {Charcot). .... 238

36. Scheme of Conductors in Cord 246

XV

XVI LIST OF ILLUSTRATIONS.

IG. PACK

37. Diagram Showiitg Relation of Motor, Sensory, and Reflex Functions

OF Cord. (Oowers) 273

38-41. Muscular Changes in Antero-Spinal Paralysis of Infants.

{Buckenne) 284

42. Antero-Spinal Paralysis. [Seguin) . - 287

43. Main en Griffe. {DucJienne) 296

44. Perimeter of Chest in Progressive Muscular Atrophy. {Duehcnne) . 30(»

45. Atrophy of Left Shoulder 208

46. Partial Facial Atrophy 300

47. Pseudo-Hypertrophic Paralysis. (Gowers) . , . . 314

48. Mechanics of Muscular Action in Pseudo-Hypertrophic Paralysis.

(Gowers) 3i()

49. Appearance of Muscular Tissue in Pseudo-Hypertrophic Paralysis.

(Charcot) 319

50. Appearance of Trophic Changes in Locomotor Ataxia. (Charcot) . . . 332

51. Course of Posterior Nerve-Root Fibres. (Clarke). 335

52. Sclerosis of Columns of Goll. (Charcot) 341

53. Method of Provoking Dorsal Clonus. (Govjers) 350

54. Contraction of Feet in an Advanced Case of Primary Degenera-

tion OF the Lateral Columns 357

55. Syringo-Myelia and Hydro-Myelia. (Leyden) 360

56. Scheme of Fibre Connection in Lateral Columns. (Flechsig) .... 361

57. Sclerosis of Lateral Columns Sc;;

58. Map of Suffolk Co., Long Island, Showing Prevalence of Endemic

tetanus . 37h

59. Retraction of Head in Cerebro-Spinal Meningitis. (Lewis Smith) . . 422

60. The Pathology of Hysteria 467

61-64. Attitudes of Hystero-Epileptic. (Boumeville and liegnard) . . 471-475

65. Exophthalmic Goitre ( Yeo) . 505

66. Charts Showing Nervous Areas. (After Herde) 532

67. The Author's Percuteur 535

68. Trophic Changes of Skin of Hand in Neuritis 539

69. Sarcomatous Neuroma. (Foucault) 547

70. Wire Hook for Treating Facial Paralysis 55;')

71. Reflex Spasm from Genital Irritation 577

72. Instrument Used for Treatment of Torticollis 58U

NERVOUS DISEASES.

INTRODUCTION.

HINTS IN KEGAKD TO METHODS OF EXAMINATION AND STUDY.

In beginning our consideration of the diseases which are to form the subject of the succeeding pages, it is well to start with systematic rules for investigation, and it is of paramount importance that we should pursue some plan which will enable us to avoid confusion, and assist us in making an accurate diagnosis by exclusion. I, therefore, propose a scheme to be used in the examination of patients, and would add a word of caution in regard to the error many of us make in too readily accepting and isolating nervous symptoms as distinct, which, after all, may be expressions of some general disorder. It too often happens that simple digestive disturbances, cholesterseraia, or perhaps ur?emic poisoning give rise to symptoms that are seized upon as the basis of a distinct nervous disease, and the error is not recognized in time to arrest the true mischief.

We are to determine the existence and relation of disorders of motility and sensation, as well as mental symptoms, defects of speech, sight, or hearing, together with the causes which enter into their production.

EXAMINATION OF THE PATIENT.

Preliminary Examination. — Sex, age, temperament, appearance, duration of present disease, existence of complicating maladies, previous history, hereditary predisposition, habits.

SYMPTOMATOLOGY.

Motility, degree of, location of loss or increase (one side or one-half ^of body?), groups of muscles or single muscles, face, trunk, or extremities, lateral or bilateral, symmetrical or unsymmetrical, loss or exaggeration of electro-muscular contractility, fibrillary contractions, muscular power, associated with deformities or contractures; atrophy or hypertrophy, general or partial ; spasms, tonic or clonic, attended or unattended by loss of consciousness; condition of reflex excitability.

Tremor. — Local or general, increased or controlled by will, "fine" or " coarse;" time of day, continuous or at intervals; subsidence or continuance during sleep; whether evoked by jarring limb, or by tapping tendons or muscles; increased or stopped by flexion or extension of foot; accompanied or not by pain ; associated or not with rigidity of joints when limb is flexed

2 17

Incodrdiriation of upper or lower extremities, variety of action in which it occurs ; gait ; aggravation by closure of eyes ; loss of muscular sense ; loss of locating power.

Sensation. — General or partial anaesthesia; dyssesthesia or hypersesthesia ; susceptibility to painful impressions ; temperature ; tactile sensibility ; sensibility to pressure ; pain, localized or general ; character of pain, neuralgic, terebrating, dull, or paroxysmal ; time when aggravated ; its associations ; time of transmission of sensation ; appreciation of form.

Disorders of Organs of Special Sense.

Eyes. — Nystagmus, strabismus, conjugate deviation (see article Cerebral Hemorrhage), retinal changes, corneal changes, pupillary changes, ptosis, diplopia, amblyopia, amaurosis. The existence of color blindness.

Ear. — Deafness, subjective noises, discharge.

Speech. — Aphasia, slow speech, clumsy speech, ataxic speech, loss of speech (mutism). Visual and auditory relations.

Vertigo. — Variety ; concomitant phenomena.

Psychical Disorders. — Illusion, hallucination, delirium, mania, melancholia, delusions, and their character, loss of memory, loss of consciousness, imbecility, idiocy, excitability, dementia.

Miscellaneous. — Character of cutaneous surface, changes in temperature of general surface or localized spots, cranial temperature, variation in salivary secretions, changes in pigmentation and appearance of hair, perspiration, etc.

Exciting Causes ; Diagnosis ; Treatment.

This list, though imperfect, will, I think, enable the observer to pursue a systematic course in examining his patient. He should, at the same time, take careful notes for future reference, so that variations in the symptoms and changes of treatment may be remembered.

Before leaving the subject of examination, I wish to refer to the value of post-mortem examination and microscopical investigation of the morbid anatomical changes. These subjects belong more properly to special works upon pathology and microscopy, but it may not be amiss to add a few hints to those already given in regard to certain important steps to be taken. In removing the calvarium the thickness of the cranial bones should be noted, as well as the condition of the diploe ; but extreme care should be em ployed, in sawing through the bone, not to wound the meninges and brain-substance beneath; for the saw-teeth may unexpectedly tear through, lacerating and injuring these parts, so that they may be almost useless for subsequent examination. After the skullcap has been removed, the

POST-MORTEM EXAMINATION. 19

observer should be on the lookout for Pacchonian bodies, and ready to recognize any adventitia that may be attached to the dura mater. The condition of the longitudinal sinus and veins which are contained in the dura mater should be examined as to their fulness, etc. ; the thickness, vascularity, color, and opacity of their tissue should also be carefully noted and then an incision may be made, and this membrane slit up with a pair of bluntpointed scissors, or it may be cut around at the level of the saw cut. The arachnoid and pia mater are- then to be inspected: the existence of effusion, either serous, purulent, or bloody; and the presence of granular deposit or vascular changes noted. The brain should be lifted back, and the cranial nerves carefully cut as near as possible to their points of exit from the skull, the optic first, and then the carotid arteries and posterior nerves ; next the tentorium, and finally the other nerves, vertebral arteries, and the spinal cord as low down as possible, taking care not to make pressure by insinuating the finger into the foramen maguum. The brain may then be removed.^ If it is desired to remove the cord, the skin and muscular tissue of the back should be divided and thrown back, and the spinous processes and laminae exposed. These latter should be sawn through on each side and carefully raised by the blade of the chisel^ When the brain is removed, it should be placed with the base downwards ^ and the appearance of the convolutions noted, the membranes having been removed.

Evidences of pressure are to be looked for, and the color is to be noticed, as well as the depth of the sulci and superficial evidences of softening or sclerosis, morbid growths, and infiltration. The organ may be turned over, and the arteries at the base inspected in regard to the existence of anomalies, aneurisms, degeneration, tbrombosis, or embolism. The fissure of Sylvius may be next examined, and the middle cerebral artery traced by sections. As to the method of making cuttings of the brain, we may, perhaps, find resort to the horizontal section of Flechsig, especially when the patient has presented before death symptoms indicative of degeneration of the internal capsule. We are enabled to carefully compare by this means the relations of the gray nuclei and the peduncular fibres. The cranial nerve-trunks are to be carefully noticed, and if any suspicious appearance is observed, a section may be removed for microscopical examination. The crura and pons are to be examined carefully for softening, secondary degeneration, extravasations and the like, and the appearance of the basal parts of the hemispheres next noticed. The brain-substance may be inspected, in other ways by cutting through the corpus callosum, and turning each hemisphere gently back, or by slicing off the brain-substance with a broad sharp knife previously dipped in water or alcohol, so that the white matter may be examined at different levels, as recommended above. The condition of the ventricles should be noticed as to the effusion of serum or blood, or the condition of the lining mem-

^ Kemoval en masse, of the brain and its membranous coverings should never be attempted; the result of such a procedure being mechanical injury, which reduces the organ to a pultaceous mass, rendering it unfit for examination.

branes. The parts at the floor of the lateral ventricles deserve special study, and the corpora striata should be inspected very attentively, the extra-ventricular and intra-ventricular parts being carefully sliced. A vertical section just posterior to the fissure of Rolando (Pitre's section) may be made. The fulness of the vessels in the deep parts of the brain, the existence of patches of softening or induration, and the pressure of cysts, tumors, or morbid growths should be looked for. It is always advisable in cases where aphasia has been a symptom during life, to carefully inspect the anterior convolutions, particularly the third frontal, which is the generally acknowledged seat of the lesion, and we may do this examining at the same time the appearance in the fissure of Sylvius, and carefully slicing that portion of the brain anteriorly, and laterally to the corpus striatum of the left side.

It is hardly necessary to allude to the importance of carefully examining the medulla and the roots of the various cranial nerves, the pyramidal decussation, and the cerebellum, and for this purpose it is advisable to remove such parts as are wanted for subsequent microscopical examination. The cord must be examined critically in cases of spinal disease, and the same directions are given for its inspection. Suspected portions may be cut out and laid aside, care being taken to secure as much of the external roots as possible. In special cases nerve trunks or peripheral nerves may be exsected for future examination, and in cases presenting iLiuscular atrophy and degeneration it is well to ascertain the morbid changes in the muscles. If we desire to use the microscope it is generally necessary to harden the tissues, although fresh nervous substance may be teased apart in glycerine or serum by needles prepared for the purpose. If we prefer the first method we may put such masses of the brain or cord as we desire to harden into Miiller's fluid, which is prepared

as follows : —

R. Potass, bichromat. 50 grammes, Sodic sulphate, 20 grammes, Water, 1600 grammes :

Or, what is better, the solution recommended by Prof. J. W. S. Arnold, of the Medical Department of the University of the City of New York :

R- Ammon. bichromat. 11 grammes, Methyl alcohol, 320 grammes, Water, 640 grammes.

Care should be taken not to secure specimens which are too large, as tlaey do not harden thoroughly, the exterior becoming hard while the interior is diffluent and useless. They should be left in the solution for a month or six weeks, but not till they become granular or cheesy, for then it is impossible to make a good section, as the tissue is apt to crumble under the knife. At the end of this time, or when the tissue is quite firm, it may be removed and placed in a fifty per cent, mixture of alcohol and water. The specimen may be examined to test its hardness by making sections with a razor from time to time. If a very thin section can be

MICROSCOPIC EXAMINATION. 21

made with a moistened razor without parting, adhesion, or crumbling, it may be considered to be in fit condition for removal from the hardening solution. A solution of bichromate of ammonium, 15 grains to the ounce of water, is an excellent hardening solution, in which the specimen mayremain until it has been uniformly saturated, and hardening has commenced, and then it is to be removed and placed in a solution of chromic acid, two grains to the ounce of water, where it is to remain until hard enough for cutting. This is the process recommended by Dieters. The specimens may be taken out and kept for use in dilute alcohol till they are needed.

When the hardened tissue is to be examined, it is to be imbedded in pith or paraffine, and either placed in a section cutter, or held in the hand. By practice, this latter procedure becomes quite easy, and very thin sections may be skillfully made. A piece of brain or a length of cord of a convenient size is surrounded by elder pith previously prepared to receive it, and bound in place by a string, or by a piece of fine copper wire. When moistened, the pith swells so that the tissue receives uniform pressure and support. If the paraffine process be that employed, the tissue is to be carefully dried and placed in a small paper mould which is afterwards filled with melted paraffine, this however should not be too hot,^ and care should be taken to exclude air-bubbles. When cool and solid the upper part of the paper may be torn away, and the specimen is ready for cutting. A flat razor is the best instrument of which I know for ordinary work. Its blade should be dipped in a saucer containing alcohol placed conveniently by, and the face of the section should be moistened from time to time. The individual holding the mould firmly between the thumb, forefinger, and second finger of the left hand, cuts away a portion of mould and tissue so that a level surface is left exposed ; then, with moistened razor, he plants the blade, and slowly cuts a thin slice of paraffine and tissue together ; this is removed by a camel's hair brush which has been dipped in alcohol, and next dropped into a small vessel containing dilute alcohol, and then placed in the staining fluid, which may be the following:—

R. Carmine (pure), gr. xx,

Glycerinse,

Aquae, aa ^ij. — M.

After being allowed to soak for several hours or days, the sections are removed and dropped into water slightly acidulated with acetic acid. They are now to be placed in absolute alcohol for a short time, and afterw^ards in oil of cloves until they become transparent. A perfectly clean slide is procured, upon which one of them is placed and a drop (not too large) of Canada balsam is next applied. * It is then covered by a thin

^ I have recently used metallic bottle caps, which may be easily procured. When the paraffine is cool the metal may be stripped off.

glass cover, care being taken to exclude air-bubbles. Various preparations are used to stain nervous tissue ; for instance, a solution of chloride of gold will stain the nerve fibres, and render them more distinct ; hsematoxylin and osmic acid are also used, and the black analin process of Herbert Major^ produces the most beautiful results. These manipulations, however, are out of place here, and I would refer the reader to any one of the excellent text-books that have appeared during the past few years for more explicit directions.

It is often necessary to make sections in all possible directions and positions, and to do this properly the microscopist must not only have practice but patience and care. It is advisable to procure at least two objectives, one for coarse appearances, and the other for minute changes, and I would suggest that these should be an "inch " and a " quarter inch."

INSTRUMENTS USED FOR THE DIAGNOSIS OF NERVOUS DISEASE.

It is essential that we should possess certain instruments which shall be more valuable and exact than our Unaided senses, so that we may not Fig. 1. only make reliable investigations, but compare from time to time such variations as may occur in the patient's condition.

Those I propose to describe are intended for examinations of temperature and sensory changes, and for the detection of altered motility.

The Thermometer. — There are several instruments made for the purpose of determining variations in temperature, and though some are of extreme delicacy, I do not think it will be worth while to recommend them, as they are bulky and troublesome, and are better adapted for experimental purposes than actual clinical use, and among these is Lombard's instrument.

In Dr. Seguin's surface thermometer we possess an admirable little instrument for testing the surface temperature. It has an expanded base, and may be applied to the surface of the body, taking care to cover the top by a perforated piece of thin rubber or leather. A coat or two of shellac varnish to the upper part of the bulb will answer the same purpose, viz., that of preventing the mercury from being affected by the temperature of the room. For the determination of deep temperature we may avail ourselves of any of the good self-registering instruments. Two surface thermometers should be used, one on the sound, and the other on the affected side of the body, and the deep temperature maybe taken at the same time for comparison. A new form of surface thermometer has recently been made in England. The glass tube is spirally coiled upon itself and enclosed in a circular box. This form has the merit of being unaffected by other than the body temperature.

West Riding Reports, vol. v.

CEREBRAL THERMOMETRY. 23

Within the past two or three years a great deal of interest has been excited by the remarkable investigations of Broca, who found that it was possible to detect deep changes of temperature in the cerebral organs by means of surface thermometers applied to the exterior of the cranium ^ Broca's observations were confirmed by those of ^ Dr. Landon Carter Gray, of Brooklyn, N. Y., and by ^Maragliano and Seppilli, two Italian experimenters. Albers of Bonn was undoubtedly the first person (1861) to suggest cerebral thermometry ; but Broca's work was the first undertaken in a systematic and fruitful manner.

By the use of six or more thermometers applied to the head at various points, with every allowance for external disturbing agencies and sources of error, it is found that the central temperature undergoes various modifications, amounting sometimes even to several degrees ; and Gray was enabled to diagnose and localize the existence of a cerebral tumor by this diagnostic means. The thermometers should be those known as Seguin's, or, better still, of the form modified by Dr. Gray. They should be tempered perfectly, and so constructed that ordinary pressure upon the bulb shall cause no rise in the column of mercury.

Apropersystemof straps (Fig. 2), -p- 9

such as has been devised by Dr.

Gray, or a cap of gum-rubber, with perforations, enables us to apply the thermometers upon both sides of the head, over the points we desire to examine. Dr. Gray has adopted the names Frontal, Parietal, and Occipital — stations relating to the positions indicated by the names to designate the places over which

the tests are to be made. A ther- Gray's system of Head straps.

mometer is to applied (after the

index column is shaken down) to these spots for a period at least of twenty minutes, and then the figures are read without removing the instruments. When a spot with increased temperature is found, the other thermometers are to be grouped about the suspected locality. Kepeated tests show more or less sameness in the readings, so that it is possible to determine that a very limited portion of the brain is the seat of morbid action. In one case Gray was enabled to diagnose a tumor before death.

1 Pr ogres Medical, 1877, quoted by Gray.

^N. Y. Med. Journal, August, 1878, p.'l31.

^ The adjustment of these straps should be made so tliat those passing over the head should go in front and behind the fissure of Kolando which divides the important motor tracts. Gray measures from the fronto-nasal fissure, and fixes the location of the fissure as 6^ inches posterior to this point.

^Dr. Gray thus details the observations he made : —

"The patient was a female, aged thirty-four. There was present a typical ' choked disk/ marked pain in the temple and brow, becoming unbearable in paroxysms, nausea, vomiting, ptosis, paralysis of the ocular muscle. The first paroxysm of pain came on January 21st. The bodily temperature ranged near the normal. Upon these symptoms a diagnosis of intra-cranial tumor was made, probably situated at the base. Placing my thermometers upon the head, I ascertained the temperature at the different stations to be as follows :

Left. Eight.

The average of the two sides, if calculated, will be found to be 96.16° on the left, on the right 99.52°, the average for the whole head being 97.84°.

The rise above the normal averages is startlingly apparent. At the Left Frontal Station it was 2.39°; at the Left Parietal, 56.0°; at the Left Occipital, 4.09°; at the Right Frontal, 5.12°; at the Right Parietal, 6.16°; at the Right Occipital, 8.56°; while the average of the leftside had mounted above the normal 2.33°, the right side 6.66, and the average of the whole head 4.33° !

This particular observation was taken as I was at the outset of my study of the subject, and was made with my first set of thermometers, which, as I have already stated, were defective. I have satisfied myself, however, that the defect amounted to but a little over one degree. If, therefore, from these figures one and a half degree be deducted, all fear of error may be dismissed ; and yet the increase is unmistakable. About this date (March 4th), I wrote Dr. Rockwell : " I shall certainly expect to see inflammatory changes from the base of the fissure of Sylvius backward along the occipital lobe, as well as that these changes shall be spread around the base of the fissure." The patient died March 16th. * ^ ^ ^ * ^ " The meninges were found

apparently normal, with the exception of a slight congestion. At the base of the brain the membranes and skull were to all appearances healthy. But a soft, jelly-like tumor, the size of a hazel-nut, was found between the horizontal or posterior branch of the fissure of Sylvius and the first temporal fissure, while the whole of the right occipital lobe was converted into a colloid, extremely vascular mass, which gave way under examination, this degeneration also extending anteriorly to the tumor as far as the fissure of Sylvius. There was no apparent disease except at these points. Upon microscopical examination, I ascertained the tumor to be a typical glioma, thickly strewn with small extravasations of blood."

Dr. Chas. K. Mills'^ has reported an interesting case of tumor of the

1 Loc. cit. 2 piiii, Med. Times, Jan. 18, 1879.

^STHESIOMETER.

brain, involving portions of the first and second frontal convolutions, in which he found that the temperature obtained over the middle frontal station averaged 1.50° above that of the other stations.

The evidence collected by the few observers already mentioned shows the normal average temperature to be about as follows at the stations designated :

GRAY.

MARAGLIANO AND SEPPILLI.

BROCA.

K. Frontal ....

L. '' ....

R. Parietal ....

. . 97 07 ...

. . . 95.39

. . . 95.79 . . . 92 84

... 94 44 ...

. . . .97 12 . . .

. . . 91.49

U. Occipital ....

L. " ....

. . . 92.66

N. B. The experiments of Gray and Broca were made during cool weather.

Gray found the average tempera ture on the left side of the head to be 93.83° ; right, 92.92°. The average temperature of the whole head, exclusive of the vertex, 93.51°. Average temperature of motor region of vertex, 91.67°. His conclusions may be summed up as follows :