The patient whom you see before you presents, in a typical form, the group of symptoms which, in the past few years, has come to play a very important part in the study of the nervous system. I refer to the condition known as cortical or Jack sonian Epilepsy. The patient is the wife of a man of an exceptionally irascible temperament, for within two weeks after the time of her marriage, she tells me that the honeymoon was interrupted by her husband beating her. This pastime seems to have been continued regularly, for fourteen years ago while she was just about to be delivered of a child, her husband knocked her down with a chair, which stunned her for some time. The child was born three days after. Again, at Christmas time, in 1886, she was struck on the left side of the head by a chair. You can see to-day the scar upon the temple which marks the place of the gash wade by the blow. Such has been heen her domestic history; and both the blow on the left side of the head and the wearying effect of many years of such an existence, may well have acted together to bring about the symptoms to be noted later. Continuing her personal history, I may tell you also that, married at the age of 17 years, she has had seven children, of whom three are now living. Has, besides, had several miscarriages. Her labors were easy, but she never was able to nurse her children. One child died at the age of six weeks, one was still-born. But while these facts hint at the possibility of specific taint, yet we can elicit no history of syphilis either in her person or in that of her husband. The family history throws no additional light upon the case, for the various members of the family seem to have been free from neurotic tendency with the single exception of her mother, who died of apoplexy at a fairly advanced age. In person our patient is rather tall, not stout, but strong; naturally of a fresh, florid complexion, one can yet detect a certain anæmic pallor, especially in the color of the lips. Let me suggest to you, gentlemen, this point in regard to your examination of your patients. One of the most difficult, and yet one of the most essential things for you to learn is, that "seeing ye shall see.' I well remember how, in early years, this Biblical phrase seemed to me a meaningless repetition. One naturally thinks that "seeing ye shall see" of course, but it is not "of course," quite the contrary, for we see continually a multitude of things which we yet do not perceive. Your clinical training ought to help you to learn to see. Now, the color of the skin depends not upon one fact alone but upon several-the thickness of the epidermis, the abundance and calibre of the capillaries, the color of the contained blood, and the color of the skin. You will see anæmic girls with thin clear skins and dilated capillaries, whose beautiful cheeks would deceive the very elect with their color. You must learn not to be deceived. So our patient is one of that class of people, commoner in Scotland and Ireland than in America, who have large and abundant capillaries near the surface. A little, even pale blood, makes a good deal of a show with such persons. To return to our patient, we learn that on April 1st, 1887, about four months after the Christmas festivities, she had a miscarriage which caused an excessive, evidently dangerous hæmorrhage. Four weeks later she tells us that she suddenly lost the power of speech, as she puts it, "could think of things but couldn't say them." This condition lasted an hour and a-half, when she had a convulsion upon the right side of her body. At her next menstrual period, about a month later, the same phenomenon was repeated. The convulsions then began to recur with increasing frequency, coming about once in two weeks, but not in any regular connection with the menstrual times. In December, 1888, she first came under my care, and when put upon treatment she managed to go along for five months without a convulsion. As to the convulsion itself she sometimes does not lose consciousness at all, more often experiences, just at the height of the seizure, a momentary unconsciousness. She is therefore able to describe her symptoms very intelligently. She feels first a curious sensation in the little finger of the right hand; this sensation or aura then spreads to the hand and is followed by a contraction of the fingers; then the hand, the forearm, the arm and neck, and right side of the face become involved; with this she loses her ability to speak. The attack soon passes off, but for a little time her speech is confused; she finds difficulty in getting hold of the right word. I should state that she has a pretty constant headache, which has lasted since May, 1887, and is always in her right temple. Also, in September, 1888, she noticed that she saw double, and thereabouts she noticed that she began to squint. The convergent strabismus of the right eye seems to be due to a paresis of the right abducens. Such, gentlemen, is the clinical picture. Now let us see what it illustrates : It is not many years since the brain was regarded as a very mysterious, but single organ. To it were, indeed, at tributed certain special intimate relations with thought, sensation, motion; but the first attempts to, in any way, analyze the functions of its complicated component parts, led off into the vagaries and futile fancies of phrenology. The absurdities of this system as has too often been the case with other and better systems entirely overshadowed the single germ of truth; so it happened that with the chaff we threw away the wheat. One solitary fact persisted. Broca had followed up the pathology of certain cases of loss of the power language, until he had established the fact that a small area just above the beginning of the fissure of Sylvius, the posterior part of the third or lower frontal convolution, just where the folds join in the beginning of that long ascending convolution which runs up in front of thefissure of Rolando, known as the ascending frontal, he had distinctly proven that there was a relationship between this area and an affection of speech now known as aphasia. He further recognized the fact that the lesion which gave rise to this affection was to be found on the left hemisphere. It is not necessary to day to enter into a discussion of the discoveries which have since been made in regard to aphasia, which in themselves constitute a marvellous demonstration of the constitution of the cerebral mechanism, which show curious relationship within the brain, between the eye, the ear, the memory, the voice and the muscles used in gesticulation. It is enough that Broca's fact proved two things: first, the existence of what we now call a centre, a portion of the brain-substance set apart to be in distinct relationship with certain fixed parts of the body, to have a distinct relation with the performance of certain functions. The other fact was, that while the two halves of the brain look alike, yet it was evident that they do not necessarily act together. Now, if one portion of brain matter were thus set apart to control one function, the further step was natural; it might well be that other functions might be found to depend upon other portions or centres, and the course of experimental and pathological study has gone on on these lines, making progress with constantly increasing rapidity until to-day, the doctrine of cerebral localization has reached an accuracy, a certainty, which so short a time ago as the year 1881, would have been deemed incredible. Not only have we widened our knowledge as regards the centres for speech, but a whole area has been mapped out under the name of the motor area, from which proceed the motor impulses to the entire body. The centres for the special senses afford still a subject for further discussion and investigation. Considering the manifold relationships between the special senses themselves and between them and all the finer mechanisins of the body, it is not surprising that many puzzling elements remain; yet it is safe to say that the principle of special centres applies equally to special and general sensation as well as motion. Again, while the problem of the relation of the mysterious phenomena which we call thought, consciousness, will, with the material substance of the body remain as inscrutable as ever, yet the principle of cerebral localization has made its way some few steps further into the darkness of the problem than was formerly possible. We know at least that the anterior convolutions of the cerebrum stand in close relationship with the processes which we designate as mental or intellectual. In short, we are following out the almost necessary consequence of Broca's one fact, to wit. that if one function be isolated in connection with one centre, then the others must be also. Do not misunderstand this isolation of functional connection. The simile has been well used that the skull contains, like the abdomen, not one organ, but many; yet the fact should not be lost sight of that these many organs are related to each other in the most intimate manner. Consider the enormous mass of white matter which a transverse section of the brain just at the level of the corpus callosum shows; this white matter represents an infinite number of nerve fibres, of connecting paths; a moment's consideration will prove to you that only an insignificant portion of these paths can be for the purpose of conducting impulses either from the cerebrum to the body, or from the surfaces of the body to the cerebrum; for, note, what a little mass of white substance is revealed in a cross section of the medulla oblongata. Now, this mass of white substance called the centrum ovale represents the enormously complex means by which the various centres are related each to each other; so that while we rightly designate certain tracts as motor, others as sensory, or others as psychic or mental, yet each centre acts, influenced by some other, in a greater or less degree. When the burned child dreads the fire, his mental condition called "dread," involves the centres of sensation which were once so pungently excited by contact with the stove, the centres for sight still retain the impression of red-hot iron, and the motor centres, I doubt not, retain enough of memory that they would on a second occasion withdraw the hand more rapidly than on the first occasion. All of these centres and more, are probably bound together when the child dreads the fire. These preliminary thoughts upon cerebral localization lead, not unnaturally, to the subject in hand, that of cortical (or, as it is often, and, as I conceive, unfortunately, called Jacksonian) Epilepsy. Various experiments had led up to a very exact localization of the centres for the arm, hand, leg and face, and these experiments, necessarily performed upon the lower animals, awaited further proof before the results could be held true of the human brain. The proofs were soon afforded by pathological experiment. Nature performs the experiment which we could not at first do. If along the fissure of Rolando, in man, there are motor centres like those proven to exist in the monkey or dog, then if these isolated areas are diseased, we should find corresponding evidences of alteration of function; or if destroyed, a corresponding loss of function. A mass of such evidence demonstrates the truth of the theory. The especial characteristic of cortical Jacksonian Epilepsy is this, that the convulsion is a partial or local convulsion. (The term epilepsy is here restricted to its original meaning of a motor disorder.) In some cases the convulsive movement is, and remains limited to a small group of muscles; the convulsions recur after the periodical manner of epilepsy; they are frequently preceded by a sensory discharge or aura, as in ordinary epilepsy, although the sensory discharge like the motor in such cases, tends to be of limited area; consciousness is frequently unimpaired, so that the patient is an interested and intelligent spectator of his own involuntary performance. Such is a typical limited cortical epilepsy; from this there are all grades in the extent of the symptoms up to a complete epileptic seizure with general convulsion, total unconsciousness and subsequent transient coma. It is both interesting and instructive to note how in some individuals the convulsions, may vary. For instance, a robust young woman under my care has at times, a convulsion in her leg only. If the discharge is more severe the convulsive movements of the leg are more pronounced, and the arm of the same side is involved; if still more severe, the opposite side of the body is involved; there seems always to be a proportiou between the intensity of the discharge and the extent of brain matter involved; but even in severe and widespread seizures it can be distinctly traced how the convulsion always begins in the same leg. Here let me give you, in passing, this suggestion; you will constantly see in your medical journals, and wlll, I have no doubt, yourselves, publish curious, rare or unusual facts which come within your observation. It is quite right and helpful that these "curiosities" should be recorded, but always remember that it is not simply because a thing is strange, or, according to a favorite phrase, "unique," that it deserves publication, ment. but because the strange or uncommon phenome- to prove the existence of precisely this arrangenon may throw a flood of light upon other related facts. You yourselves will miss the value of your curious fact unless you seek to discover its relation to other facts which may be of common occurrence and yet not fully understood. Now, the observation of such a case of partial or local epilepsy, of how the various groups of muscles are, one after another, thrown into convulsion, has a value far greater than merely to record a curious fact. One can imagine that the sensory centre for the arm being diseased and carrying on its functions irregularly, should send to the motor centre for the same arm a rush of orders all at once, setting the motor centre into confused activity and thus setting up a convulsion limited to the arm That some cases of partial epilepsy are thus due to disorders, not so much of the motor centres in the first place, as of the sensory centres, seems probable from such facts as these. We know that in some cases, some local irritant at a distance from the brain, by sending in continual irritating impulses, can and does cause epilepsy. The proof is found in the cessation of the epileptic seizures upon the removal of the cause. Here let me again give you a practical point. You will frequently be warned to look out for these sources of reflex irritation. Naturally you will look for some spot distinctly painful, some irritation of which your patient complains, but if you stop here you will rarely find the point of reflex irritation. You will constantly miss your opportunities. The fact is, that the irritant does not usually cause a distinct pain, a conscious sensation, but that from some point a series of slight but steady irritant impulses are being constantly sent in which ultimately wears out the sensory centre. In the first place, it throws light upon the nature of other and severer forms of epilepsy. When you witness an ordinary general epileptic convulsion, the general tumult is so great that it becomes quite impossible to unravel the tangled skein of symptoms, here are tonic and clonic convulsive movements, all the muscles of the body seem involved, we can tell nothing of the sensory conditions, for the patient becomes totally unconscious, in short, motion, sensation and intelligence are so profoundly involved that one cannot, by separating the symptoms, come at any fair explanation of the nature of the phenomenon. But in a case of limited epilepsy we see, in miniature, the process going on, the patient being conscious can give an account of the sensory condition, we can watch the character and progress of the convulsive movements and we see this fact first of all, that the motor disturbance is not set up by an effort of the will, but rather in spite of it. Here, to begin with, is a demonstration of the fact that motion may be set up independently of the mental control, a fact which bears out the theory of separate functions for separate parts of the brain. Our patient with limited epilepsy, very commonly, but not always, has an aura, a sensory dis-origin of some cases of cortical epilepsy, is to be turbance just before the convulsive movement, and usually felt by her as being in or near the member involved in the convulsion. If there be sensory as well as motor centres, then we should expect, from the common necessities of use, that the respective centres for the same part should be in habitual close connection. For instance, it is essential that the sensations affecting the right hand and arm should very readily bring about motion of the same parts, otherwise the sensations would fail frequently to protect the arm from injury or enable it to perform work required of it. This aura preceding the cortical convulsion, tends Did you ever undertake to bring up a fairly good but active boy? Well, the boy may not be painfully bad, but he can wear you out. So, for instance, the process of dentition does not cause any very definite pain, but is a frequent cause of convulsions. Another fact which goes to prove the sensory found, in a fact occasionally noted that the patient can, at times, block off a seizure by a strong effort of the will. I have, for instance, a patient who usually has her attacks at night, when she is wakened by the aura, she groans. If, now, her husband wakens quickly and gives her a vigorous shaking, she finds that the convulsive movements do not come on; if he is too slow, then the convulsion completes its course. Such a fact seems to show that to the same motor centre, impulses come from different directions, those from the sensory centre tending to start the motor centre into confused activity, those from the psychic or mental centre tending to control, or, as it is often had a particularly severe convulsion in my office, called, inhibit the motor centre. In some cases of cortical epilepsy the patient describes no aura whatever. In such a case it is probable that the lesion is purely one ofthe motor centre. Before leaving this point, however, let me say that the presence of an aura does not enable us infallibly to diagnose the precise locality of the lesion, and this, for the reason, that the relations of sensation and motion are so intimate that we cannot entirely separate them as to cerebral localities and their mutual interaction. You see, now, that our simple case of cortical epilepsy has considerable importance as one of the proofs of cerebral localization. Now, let us take up another feature. You remember how I described the convulsions in a certain patient as always beginning in the left leg, if severe, involving the left arm, and if very severe, involving the opposite side of the body. Let us assume that the disturbance began in the leg centre in the motor area of the right hemisphere. Let us then picture what goes on. While we cannot describe what is that mysterious process which goes on in the brain cells when they act, yet we can use a simile to help us. Let us conceive that each brain cell contained a minute quantity of dynamite, the explosion of which caused a muscular contraction in the related muscle fibre (we must also imagine that the brain cell was able to become re-charged after a little time). Now, if the adjacent cells were jarred by the explosion, we could imagine a lot of them going off in rapid succession. It would then be expected that the greater the number of cells involved in, and the more sudden the first explosion, the greater the number of adjacent cells which would receive the shock and be themselves discharged. If the initial explosion in the leg centre were not severe, the leg centre alone would be involved, but if more severe, the adjacent arm centre would be brought into activity, and if the series of explosions were now severe, the cortical matter of the and not only were all the motor centres invaded, but the mental as well, and for a brief space she had a furious attack of mania, which required the control of four able-bodied men. You see, then again that our limited epilepsy helps us to gain some insight into the processes involved in the ordinary and graver forms. When you conceive that in a general epileptic convulsion, the discharge takes place not at a limited area, but over a large part if not the whole of the cortical substance, at once you can readily understand the wide distribution of the parts involved. Again you can understand why an epileptic falls into a comtose sleep. His cortical cells are all, for the time being, exhausted, and not until the cells have drawn from the blood a fresh supply of explosive material, can the ordinary and regular discharges be again established. (To be continued.) A CASE OF PERIOSTITIS ALBUMINOSA OF OLLIER.* BY THOMAS R. DUPUIS, M.D., KINGSTON, ONT. GENTLEMEN, The case which I bring before you to-day is one of those diseases which acquire interest by their rarity. Rare diseases when discovered should be brought to light, and exhibited especially before medical associations, for the purpose of awakening attention to their existence. We are so constituted that many things pass us unnoticed every day, and are hence accounted rare, for which, were on the look out we should find to be perhaps of very frequent ocurrence. if we SO It is with diseases, and with the symptoms of disease; and hence the propriety of noticing many things that in themselves seem trivial. This is my apology for bringing the following case before you. In May, 1888, there was brought to me from New York State, a young man aged 22 years, to be examined and treated for a peculiar kind of swelling on the middle third of the anterior part of the tibia. The medical gentleman who had attended him there, came with him and stated to me opposite hemisphere would go off or be discharged. Indeed it seems pretty clear that some such process does occur, and the cortical substance seems to be involved in all directions. It reminds me of a fire in the grass burning rapidly at all that he was completely puzzled in the case. had supposed it to be an abscess, and with this points, around the circumference. For instance, my patient with the leg epilepsy, on one occasion, He * Read before the Ontario Medical Association, June, 1889. |