Case 1. Laundress, æt. 70; ulcer began at 56; situated on side of face; had destroyed the lateral cartilage of the nose and perforated its septum ; reached from lower eyelid to border of upper lip.

Case 2. Farmer, æt. 53; ulcer commenced at 48; situation, cheek.

Case 3. Laundress, æt. 60; commenced at 55; excised.

Case 4. Female, æt. 69; commenced at 64; excised; situation, cheek.

Case 5. A smith, æt. 52; situation, cheek; excised; disease returned in one and one-third year.

Lymphatic enlargement was not noticed in any case. The chloride of zinc paste was used in each case. The histories are all incomplete, because the disease is so chronic that the patients were lost sight of. Mr. Geo. Lawson (Trans. Clinical Society, London, '72, v. 26) reports a case of a laundress, æt. 62, had commenced eight months previously, situation left upper eyelid, extended onto nose. Removed ulcer and applied potassi cum calce. Patient returned one year later with the wound not healed. Removed more extensively. Patient was observed for four months then lost sight of.

Mr. C. Higgins (London Lancet, '77, 1, 682) Female, æt. 54; appeared at 41; cheek. Three different excisions were made. Involved cheek and nose. Chloride of zinc paste was used. Patient left hospital in good condition. Stated that her daughter had had an obstinate ulcer on the face.

Mr. Curting (London Lancet, '63, 1, 207): Male, æt. 53; of eight years' duration; situation, eye. Burning proved unsuccessful. Plastic operation was performed and patient did well as long as seen.

Dr. W. J. Warren (Indian Med. Gazette) reports three cases.

Dr. G. H. Schwartz, Bonn, '71, reported one case.

Dr. W. J. Warren (London Lancet, '73, ii, 263) reports two cases.

These fifteen cases, added to the fortytwo mentioned in the paper, plus the case reported, make fifty-eight cases in a 1. He did not believe there are sixty cases reported. The literature is very scant and

almost all English. Most reports are made by gentlemen connected with the large London hospitals. We do not find much help from the German literature, because they do not differentiate it from epithelial cancer (epithelial krebs).

Although he thought the actual cautery to be the best treatment yet, he sincerely doubted its ability to effect a cure after ulceration has commenced.

It was first called "The Rodent Ulcer of Jacob," because it was first described by Dr. Jacob, of Dublin, in the Dublin Hospital Reports, iv, 1827, reprinted in the Dublin Medical Press, 1860, under the title of "An Ulcer of a Peculiar Character which attacks Eyelids and other Parts of the Face."

He thought the Doctor was to be congratulated upon his treatment. The ulcer had advanced until it wanted but three lines of the inner canthus of the only remaining eye. The object was to check the extension in this particular direction. It is now six months since the operation and the disease had not yet reached the eye.

DR. DRURY said while epithelioma in its ordinary manifestations is not a very rare disease, the form-if it be a form of epithelioma-known as rodent ulcer must be very infrequent, since the essayist in his elaborate paper has spoken of only fifty recorded cases.

The point of greatest interest is the histology of the affection. Most authorities now concede it to be cancerous in character, and the tendency of investigation seems to confirm this view.

In 1879, Drs. Tilbury and Colcott Fox, in a paper accompanied by microscopical specimens, presented to the London Pathological Society, attempted to demonstrate that the disease was epitheliomatous, and that it started from the external rootsheath of the hair-follicles. Dr. Thin maintains that rodent ulcer is a cancerous affection of the sweat glands. He traces the origin of the cell-growth to the epithelium of these glands.

Hume (British Medical Journal, January 5th, 1884) concludes from the examination of eight cases that it is of the same nature as an epithelioma, but differs patholog ically in the mode of development of its cell-growth, just as it differs clinically in the absence of gland infiltration, and in its slight general malignancy.

Fox says non-implication of lymphatic glands, and absence of secondary infiltration of internal organs are due to the excessive slowness of growth, and to the very slight activity and absence of wandering of the cells, and to the obliteration of both the lymph and blood-vessels as the growth progresses.

Mr. Paul (British Medical Journal, April 19, 1884) concludes that the disease cannot be ordinary epithelioma, and that, if a sufficient number of cases were examined, all the various epithelial structures would be found affected. He therefore thinks it probable that the disease originated, not in any particular gland, but in the skin as a

whole.

DR. WENNING remarked that it is difficult to see how the individual's occupation could predispose to this disease, since, so many are exposed to the same cause and yet so few cases occur.

Meeting of Jan. 12. 1885. DR. HEIGHWAY, G. A. FACKLER, M.D., President pro tem., Secretary.

Local Diagnosis of Diseases of the Spinal

Cord.

DR. ZENNER spoke of the local diagnosis of diseases of the cord. He presented a number of patients, and also a diagram of a section of the cord, to illustrate his theme. He pointed out on the latter the following portions of the cord:

The antero-lateral columns containing the pyramidal tracts, and the cerebellar tracts; the posterior column containing the columns of Goll and Burdach. In the grey matter are situated anteriorly the ganglion cells, posteriorly the round cells, and at their junction the spindle cells forming Clarke's column.

What we know of the functions of the various divisions we have learned from experiments and pathological changes.

The functions of the pyramidal tracts we know best of all. They convey motor impulses. They contain the motor filaments passing from the central convolutions to the ganglion cells in the grey matter.

The anterior or direct pyramidal tract passes up to the same side of the brain, the posterior, or crossed to the opposite hemisphere.

The remaining part, antero-lateral column, probably contains only associating fibres which connect the parts of the cord at various levels.

The cerebellar column can be directly traced to the cerebellum. There probably exists some connection between this and Clarke's column. This view is based upon pathological conditions, and anatomical relations, although their functions are not known. The posterior part of the cord possesses sensory functions.

Tactile sensibility and muscular sense are conveyed through the fibres in the posterior column. Sensations of pain and temperature are conveyed through the grey matter. All pass to the other side of the cord after entering. The fibres of muscular sense probably cross only in the medulla oblongata, although recently it has been claimed by some that they cross immediately. The column of Goll conveys fibres of muscular and tactile sensation, terminating in the grey matter in the medulla oblongata.

Burdach's column contains probably only associating fibres.

tion of the cord possess motor function and The ganglion cells in the anterior por

also other functions.

It is, for instance, known that infantile paralysis is attended by lack of growth of the bones, and hence some of the ganglion cells may be the trophic cells of bone. Very recently Schultze reported a case of syringo myelie involving the posterior part of the grey matter, which was attended by changes in the skin, joints and nails, indicating that the trophic centre for these organs are situated in the posterior part of the grey matter of the cord. It has been also demonstrated that the centres for various functions are situated at various levels. Disease of that part of the cord situated in the cervical region is attended by difficulty in respiration, and changes in the heart's action.

Dilatation of the pupil attends irritation of the cord in the region of the 7th cervical vertebra, while contraction follows destruction of the cord in this neighborhood.

The situation of the centres for some of the vegetative functions is pretty well established. Those controling the bladder, rectum and genital functions are known to be in the lumbar region. Kirchhof reports a case in which the destruction of the cornus terminalis of the cord was followed by paralysis of the bladder.

The bladder disturbances are often puzzling and difficult to understand, due to the fact that two functions are exercised, acting

in a contrary manner, viz., constriction and dilatation, and that in health it is partly under the control of the will. If the cord in the lumbar region be destroyed we, notice a paralysis both of the compressors and constrictors, and we have a continual flow of urine from a bladder, which is constantly distended.

If the entire cord is involved by disease, there can be no question of a local diagnosis. But many diseases are confined to a distinct portion. These are termed systematic, or system diseases of the cord. The first of these referred to by the speaker is locomotor ataxia, in which the posterior part of the cord is involved. The symptoms are mainly sensory, the characteristic pains, perversion of sensation, the band like pressure around the waist, formications, anæsthesia to some extent, absence of tendon reflex, ataxia, trophic changes and pathological changes in joints, nails and bones.

The speaker presented a patient illustrating this disease. Three years ago she noticed the lightning pains, within a year impairment of her gait. At present none of the ordinary symptoms of locomotor ataxia are wanting-ataxia, perversion of sensation, band around the waist, formication, absence of tendon reflex, irregularity of pupil. Absence of its response to light but contraction when patient looks at a near object.

The speaker here presented a second case of locomotor ataxia, and contrasted the gait of this patient with that of the first. The latter threw out her legs loosely, but did not use any control in bringing them to the ground, while in the former we notice a more constrained gait. The man has learned to hold the muscles rigidly, not allowing them free. play, and hence the inco-ordination is less marked. The second patient observed the first symptoms 15 years ago, and these were ocular symptoms. At first double vision which was followed by blindness of one eye. The ataxic gait has been of nine years duration. There is some anæsthesia, slight and only in certain places. Some loss of muscular sense, and and absence of tendon reflex. In neither the patients are there any trophic changes. In these cases the disease is located in the posterior portion of the cord. The absence of the tendon reflex indicates that the disease involves Burdach's column in the lumbar region.

The speaker desired especially to call attention to three symptoms, which taken together are very valuable in making the diagnosis of locomotor ataxia. These are the absence of the tendon reflex, the lightning pains and the ocular symptoms. The second patient has now paralysis of the levator palpebræ and of the internal rectus, muscles supplied by the third nerve. The condition of the pupil referred to above is termed the Argyle Robertson pupil. The speaker believed that he had been unable to make a diagnosis of locomotor ataxia when but two of these three symptoms are present. This he illustrated by relating two cases, in the first of which the lightning pains manifested themselves during a period of 4 or 5 years. One month ago the absence of the tendon reflex was detected. These two symptoms coming on in this manner left no doubt in speaker's mind of the presence of locomotor ataxia.

In the second case, seen in consultation, the question as to the presence of an intercranial tumor arose. There was some pain in the head and paralysis of some of the occular muscles. The speaker noticed, however the Argyle Robertson pupil, and made a probable diagnosis of locomotor ataxia. Since then lightning pains have become a prominent symptom.

In contrast to the value of these symptoms the speaker mentioned two other cases where the ordinary symptoms of locomotor ataxia might be very deceptive.

One of these was a man whose gait appeared to be typically ataxic. He suffered also with genital and visceral symptoms, anæsthesia, absence of patellar reflex, yet in this case there was no question of the existence of locomotor ataxia. There were no ocular symptoms, no pains. The trouble came on after a fall which produced a lesion in the lumbar region of the cord.

The other case was one which was later presented to the Society, in which there was some anesthesia, loss of virile power, and bladder symptoms, with disturbance of gait, which might be supposed by some to be ataxia.

In this case there were no pains, no ocular symptoms, and patellar tendon reflex, instead of being absent, was exaggerated, and locomotor ataxia could be very safely excluded.

The next class of systematic diseases referred to by speaker is that usually termed lateral sclerosis. This was first described

by Erb in 1876. In this the prominent symptoms are paralysis of the limbs, together with rigidity of the muscles, and spasmodic contraction. It is supposed that the lateral part of the cord is involved The paralysis is due to disease of the pyramidal strands. The rigidity and exaggerated tendon reflex action of the muscles is due to involvement of the ganglion cells, producing not destructive but irritative changes. Patient was here presented, suffering with partial paralysis of the lower limbs for six years. There is some weakness of the muscles of the lower extremity, and especially some spasmodic contractions. Slight weakness of the bladder shows that other parts of the cord are also involved.

But cases of this kind are rarely uncomplicated. In most of those reported other than motor symptoms have been present, and when post mortem examinations have been held, disease has also been found in other parts of the cord.

Westphal says that no uncomplicated case of lateral sclerosis exists except in connection with general paralysis.

The most uncomplicated case seen recently by the speaker was one seen in consultation with another physician in Newport, in which, with the exception of some bladder disturbances there were manifest only motor disturbances.

toms. Still there is a question in many cases as to whether the disease is central or peripheral. Erb has recenlly described cases which he calls juvenile paralysis, where only muscles of the upper arm are involved, which he considers a peripheral disease.

The distinguishing features are the absence of fibrillary twitchings and the rapid development of the reaction of degeneration.

There is another class of cases, which do not depend upon primary changes in the gray cells, called multiple neuritis. Here we have sensory in addition to motor symptoms. Speaker reported a case of this kind recently seen by himself.

The speaker had hoped to show the Academy a number of cases of muscular atrophy. One with atrophy of the muscles of the thumb and the interossei, and a second with atrophy of the deltoid only. Both he considered to be the beginning of progressive muscular atrophy.

It had only been his intention in connection with these cases to call attention to the location of the centers for these various muscles. The groups of ganglion cells, the centers in the muscles, are arranged in the cord from above downwards in a manner somewhat similar to the position of the muscles with which they are related. Thus, those for the muscles of the hand are in the lower cervical and upper dorsal seg

The third class of systematic diseases mentioned includes those cases in which the anterior gray matter is diseased: infantile paralysis, the acute and sub acute polio myelitis of adults, progressive muscular atrophy, etc. In these cases the large ganglion cells in the anterior part of the gray matter are involved. The symptoms are those of atrophy and paralysis of muscles. The ganglion cells, the nerve fibres passing from them, and the muscular fibres in which they terminate, may be considered as one organ. The disease in any part will produce exactly the same symp

shoulder are higher up in the central part of the cervical region. Those for the muscles of the arm lie between these two. The same is true for the other parts; the ganglion cells for the muscles of the foot are in a lower part of the lumbar region of the cord than those for the muscles of the thigh. But this arrangement does not hold good in all instances. The speaker here presented a case of wrist-drop from lead poisoning, which he considered to be due to an anterior polio-myelitis. He called attention to the fact that while the extensor muscles of wrist and fingers were paralyzed the sphincter remained intact. All these muscles are supplied by the same nerve, the musculo-spiral, but their centers in the cord are at different levels, the center for the supinator being on the same level with that for the deltoid and biceps. speaker reminded the members of a patient he had presented to them last year, where the supinators, deltoid and flexors of elbow were all atrophied. A similar rela

The

tion is observed in the lower extremities. The muscles on anterior aspect of thigh, the quadriceps and sartorius, are supplied by the same nerve, the crural. But in cases of poliomyelitis they do not always atrophy together, for the center for sartorius is higher than that for the quadriceps; it is probably in same level with the center for the sartorius.

The last class of system diseases mentioned by the speaker was the amyotrophic lateral sclerosis of Charcot. In these cases there is usually at first paresis or paralysis of a member, then rigidity and finally atrophy of the muscles. The disease usually begins in the lower extremities, passes then to the upper extremities, and finally involves the muscles supplied by cranial nerves, with paralysis of the tongue, difficult or impossible phonation and swallowing, involvement of respiratory centers and death. The symptoms are caused by first disease of the lateral columns, then irritative and finally destructive changes in the ganglion cells. The speaker, after giving a brief history, presented the photograph of a patient, revealing the disease in its last stages, in which could be seen the atrophy of the muscles of legs, contraction of flexors of fingers, and entire loss of expression in the facial muscles.

DR. WHITTAKER remarked that the cases of locomotor ataxia presented were typical illustrations of the chief symptoms of the disease. He was, however, struck by the fact that the reporter had omited to lay any particular stress upon one symptom-the inability of the patient to stand with his eyes closed. He would rather place this - among the cardinal symptoms, almost as valuable as the ocular disturbances. The percentage of the latter is greater than that of the former. Attention had been called especially to this particular symptom by Brown Sequard. It is usually first noticed while the patient is washing his face. It is present in about 92 per cent. of cases, and is called the Brach Romberg symptom, after its first observers. The speaker saw the first case in this city in which a diagnosis was made of amyotrophy. The patient was a lady, who had been under the treatment of a number of physicians, and a number of diagnoses had been made. What led the speaker to make his diagnosis was the rigidity with paresis of the muscles of the legs. The case was of 10-20 years standing.

Most of the members present would certainly be loth to class a case of saturnism with progressive muscular atrophy. True there is atrophy present, yet it is an entirely distinct disease, distinguished especially by the order in which the muscles are attacked.

We have besides in saturnism as prominent symptoms, colic, arthriditis, encephalopathics, etc. Brain symptoms are only present in muscular atrophy when the case is complicated with bulbar palsy.

DR. C. O. WRIGHT desired elucidation upon one point: does this disease ever become cured? He narrated the case of a man in whom the disease had existed for ten years. For five years the patient had

been confined to his room. Very few of the symptoms described this evening were not evident in this case. For weeks he had no control over bladder and rectum. Two or three times he had been given up to die. He suffered excruciating pains, yet during the past summer had been able to go down the stairs. The symptoms are decreasing, and the patient is growing stronger. The antecedent cause is probably syphilitic in character.

DR. CLEVELAND said that it is claimed by Hamilton that the disease can be cured. Such cases are probably of specific origin. The diagnosis of locomotor ataxia is comparatively easy if we take into consideration the diagnostic points presented by the speakers of the evening. The tendon reflex may be present even in exaggerated form. The speaker related a typical case of locomotor ataxia of eight months' duration. It commenced with lightning pains, inability to walk with eyes closed, and there followed some absence of sensibility, pronounced bladder symptoms, yet the tendon reflex was exaggerated.

DR. RANSOHOFF inquired in regard to the frequency of ulcerative conditions of the skin occurring in spinal disease. He desired to report one of the most obstreperous cases of ulcer of the foot. It occurred in a man thirty-six or thirty-seven years of age, with indirect syphilitic history, although there was no evidence of wellmarked secondary or tertiary manifestations. The trouble commenced when the individual was ten years of age. There was a thickened condition of the skin on the soles of the feet. Six or seven years ago the condition became so painful that the patient was compelled to seek his bed for weeks at a time. When speaker first