NEUROLOGICAL FRAGMENTS.

1472 circulation, therefore,

comes gradually to a standstill, the meanwhile showing all the classical symptoms of acute anæmia except the pallor, and at the necropsy antemortem clots in the heart bear eloquent witness to the - chronicity of the process. Sometimes, however, the heart is more suddenly stopped by engorgement of its right side-a condition which may be temporarily relieved by bleeding. The main factor in producing this fundamental condition is, I think, inadequate peripheral resistance, due to extensive dilatation of the peripheral vessels ; the great utility of digitalis is due to its stimulating influence on the walls themselves of the peripheral vessels, the comparative uselessness of strophanthus to the fact that it does not thus affect the vessels, only the heart; and the impotence of strychnine to the fact that the vaso-motor mechanisms through which it normally contracts the vessels are, in the cases I have been considering, out of gear. Cardiac failure is no doubt a factor in producing this fatal condition, sometimes Pericardial effusion is one of the even an important one. ,many results of vaso-motor paralysis ; I much doubt whether it is ever of itself a cause of death. (Edema of the lungs is also in most cases due to the same cause which produces oedema elsewhere, and therefore not accurately to be assigned as a cause of death except in certain cases, of which I myself have seen very few, but on which Mr. Simon, whose - experience of beri-beri is incomparably greater than mine, lays stress. In these cases cedema of the lungs may occur and result in death before the general blood pressure has sunk to a dangerous level, owing presumably to some local "condition of the pulmonary vascular areas. It is preeminently in these cases that Mr. Simon’s glonoine treatment often tides a patient over what would otherwise be a fatal

patient

"crisis.

TREATMENT.

Diet.-The addition, by my immediate

predecessor in .charge of the hospital, Dr. Leask, of three ounces of wheat flour to the dietary of the beri-beri patients was followed by a striking fall in the death-rate, which was maintained, more or less, up to September, 1891. It is tempting to regard these two facts as having the relation of cause and effect, and Dr. Takaki’s success in abolishing the disease from the Japanese navy by modifying a previously insufficiently nitrogenous diet, simultaneously however with other sanitary reforms, supports this view. Environment.-It is of course of paramount importance to the patient from the influence of the beri - beri miasm when this can be done ; but even when it cannot, as at the Tan Took Seng Hospital, certain measures may be adopted to minimise its evil influence. I found that after a beri-beri ward had been long in occupation its ’inmates began to do badly and the death-rate to rise. After emptying the ward, scrubbing the floor and beds with a corrosive sublimate solution and spraying the walls with the same, and then leaving it exposed to the sun and air for a few days (measures recommended by Pekelharing) it could be occupied for a month or six weeks before the recurrence of the same phenomena necessitated the repetition of the cleansing. Clothing.-The provision of an extra blanket and of a Channel jacket for such of the patients as seemed likely to be endangered by cold was found very useful. Drugs.—Drugs are mainly useful to tide over crises, for which purpose they are very valuable. A beri-beri patient with cedema (if not due to anaemia) lives in a state of unstable equilibrium, liable to the sudden onset of various crises, which may sometimes be tided over by suitable means. Glonoine (1 per cent. solution) was introduced several years ago by Mr. Simon for the treatment especially of oedema of the lungs in early cases ; a hard pulse and the usual symptoms of lung oedema are the indications for its administration. It produces its effect by dilating the peripheral vessels generally, so relieving the gorged lungs. I found at theTan Took Seng Hospital that glonoine was habitually used in nearly every case of beri-beri with threatening symptoms, whatever the state of the circulation. Considering that in most of these cases excessive vaso-dilatation was the main cause of the symptoms, it would seem a priori that the drug should have been injurious ; but I never could satisfy myself that it had done harm, and it certainly ofcen did good, temporarily at any rate, even in such cases as Case 19-e.g., presumably by its action as a cardiac tonic. When the arterial pressure is approaching a .dangerous ievei digitalis is an extremely useful agent, chiefly, believe, because of its effect on the walls themselves of remove

Taking pulse,

and iowereu

temperature always

uie.

i imve,

however, seen a small number of patients presenting all these symptoms who recovered, thanks to the admirable way in which they were watched, and then digitalis or digitaline

by Mr. Aeria. We found that the large digitalis required soon deranged the stomach and were obliged to resort to digitaline hypodermically until my small private stock was exhausted. Strophanthus I found to be useless, or almost so, in cases in which digitalis was eminently useful, a fact which strongly confirmed me in the view that the latter drug produces its effect by its action directly on the peripheral vessels. In a different class of cases-convalescent patients who were suffering only from the resulting widespread muscular paralysis and wasting-liquor strychcias, by the mouth or hypodermically in frequent small doses, seemed to be of some slight use. Addendum.-The phenomena presented by a certain class of beri-beri patients, not illustrated by any of the aboverecorded cases, so corroborate the views expressed as to administered to them doses of

the mode of death in beri-beri that it seems desirable briefly to describe them. In these cases oedema is a very marked feature, and as the disease pursues a very chronic course it attains extraordinary proportions ; the whole body is intensely bloated, the features become almost indistinguishable, the scrotum and penis enormously swollen, and the legs and thighs attain double their normal girth, or more. This condition persists for months, the patient usually dying from some intercurrent disease, the water-logged tissues being of low vitality ; sometimes asphyxia ends the scene, the patient being slowly drowned by the rising flood in the thorax. Pest mortem the heart is found to be enormously enlarged and hypertrophied. In such a case the fall of blood pressure, due to widespread vaso-motor degeneration, has been prevented from attaining the fatal point by a compensating cardiac hypertrophy, so that the circulation is maintained until the results of the continuous leakage from the vessels-an effect of the vaso-motor paralysis which there is nothing to obviate-produces its inevitable though long protracted effect. In such a case the cardiac nerves must have escaped degeneration, so that the familiar signs of this condition will have been wanting in the history of the case, or, at any rate, if this condition ever did exist in any degree at an early stage it must have been recovered from.

NEUROLOGICAL FRAGMENTS. BY J. HUGHLINGS JACKSON, M.D. ST. AND., F.R.S., PHYSICIAN TO THE NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC ; CONSULTING PHYSICIAN TO THE LONDON HOSPITAL.

(Continued from p. 253.) No. XII. ABSENT KNEE-JERKS IN SOME CASES OF PNEUMONIA.INACTION OF THE INTERCOSTAL MUSCLES IN RESPIRATION WITH GOOD VOLUNTARY ACTION OF THE SAME MUSCLES, IN A CASE OF "LATENT PNEUMONIA." I HAVE recently found the knee-jerks absent in some cases of croupous pneumonia ; absent in three, present in three others. Very likely the absence of these jerks in cases of pneumonia, or in some stages of it, has been noticed before. I wish to draw attention to the case of a male patient aged twenty-three, whom I first saw on Dec. lst with Mr. Herbert C. Wilkin, of Cornwall-road, in which case I did not discover by auscultation and percussion any signs of involvement of any part of either lung, although the temperature (105° F.), rate of respiration (44), and pulse (90) were of the pneumonic character and relation. The knee-jerks were absent. I think, as Mr. Wilkin did before I saw the patient, that the case was probably one of pneumonia, so-called "latent pneumonia "-some deepseated patch in the lung. But I think, considering a symptom to be presently mentioned, that it was one of myelitis too, or at least that there was some very local morbid change in the thoracic spinal cord. I do not mean that there was pneumonia "ccmplicated with"myelitis or some other morbid change of part of the central nervous system, as will be understood when I add that, since observing

1473 the case of this patient, I have surmised that in cases of ordinary undoubted croupous pneumonia also there is some morbid change of the cord caused by pneumotoxin. I suggest that the central lesion is the cause of the nonpulmonary symptoms of pneumonia, the high temperature, rapid respiration, and infrequent pulse (infrequent, I mean, only in relation to the respiration rate). I do not think the local pulmonary inflammation would produce such symptoms in such relation. There was in Mr. Wilkin’s patient a symptomatic condition (so to say, a double one) which I have never observed before in any kind of case; no doubt I have overlooked it. The patient’s intercostal muscles acted not at all during his ordinary (but very frequent) breathing (respiration proper), but they acted perfectly when he drew in his breath when told to do so (voluntary movement). During respiration proper, whilst, as said, the intercostals did not act, the diaphragm acted well. perhaps in too short excursions, and also frequently ; in other words the breathing of this patient was solely diaphragmatic. (The lowest part of his chest everted in inspiration--respiration proper-but the diaphragm by itself can evert the lowest ribs.) In the voluntary movement the intercostals acted well and the diaphragm not at all so far as I could make out, the epigastrium sinking ; that is to say, the voluntary movement was made as a healthy adult male would make it. We see that the fact that a patient can expand his chest walls well by his intercostals when told (voluntary movement) is no proof that the other, the true respiratory movement of them, is present ; in Mr. Wilkin’s patient there was loss of the automatic movement with persistence -of the voluntary movement of the same muscles.1 The next day Dr. Barlow saw the patient with us. (Temperature, respiration, and pulse about the same as when I first saw him.) He confirmed the observations I made the previous day. I was particularly interested in his agreement that the intercostal muscles did not act in respiration proper, and that they did act in the voluntary movement of so-called forced inspiration." At no The patient did well ; his knee-jerks returned. stage of his illness was there any other paralysis discovered than that signified by inaction of the intercostal muscles in respiration proper ; these muscles on his recovery acted normally both respiratorily and voluntarily. I infer, from the consideration of certain of Gaskell’s most important researches, that in this patient the inaction of the intercostal muscles in respiration proper was owing to loss of function of lateral horns in the thoracic region of the cord ; if so, the respiratory (medulla) centre (the lateral horns being, I presume, for respiration proper normally subservient to that centre) failed to effect anything upon the intercostal muscles, although it continued to act on some other of its subordinate centres of the cord, those which are for the immediate supply of the diaphragm. The voluntary service of the intercostals in drawing in the breath when told (so-called "forced inspiration ") is of cerebral initiation ; indeed, the word voluntary implies that. The fibres engaged in this voluntary service of the intercostals are, I suppose, some of the fibres of the pyramidal tract, which, evading the respiratory (medulla) centre, pass direct from the cortex cerebri to cells, not of the lateral horns, but to cells of the ventral part of the anterior horns, to those cells of those horns to which other fibres of the pyramidal tract go. (I think that during such voluntary, non-respiratory, services of the intercostals the respiratorymedulla-centre is inhibited by fibres from the cerebral

AN INTERESTING CASE OF CEREBRAL HEÆMORRHAGE. BY HENRY T.

BENSON, L.R.C.P. LOND.,

&c.

THE interesting points to my mind raised in this case were follows : the extraordinary absence of symptoms pointing to the extensive lesion and the suggestion that a sudden jerking of the head backwards might have caused death. The patient was a man forty-five years of age, a farmer, slenderly built, moderately temperate, and whose family history was good. On Dec. 9Gh he went to a shed to give n calf a drench ; in doing so the calf plunged, and in t-rning toavoid it he suddenly threw his head backwards. I saw him on; Dec. llth, and lfound him suffering from intense pain and rigidity of the neck, with a few tender spots about the occipital region. The temperature, pulse, and pupils were normal, and with rest and light diet he appeared better. On Dec. 24th there was pain over the farehead, with tenderness over the same region, and also at a point half an inch below and two inches to the left of the occipital protuberance. The tongue was coated; the pupils were equal and responded both to distance and light, but showed some slight intolerance to light and sound. I looked for paralytic symptoms in the face, eyes, mouth, throat, and extremities without result. He had an uneasy feeling about the right arm, but I could not detect any motory or sensory impairment; the It flexes were normal, the pulse was well filled, regular, and not easily 80 permincte; the temperature was 99.2° F.; the heart was normal and the appetite fair ; be was able to sleep’ from five to six hours at a time naturally ; the functions were performed regularly ; he was cheerful in his manner, but said he did not feel quite so well as he had been a day or two before. I saw him again on Dec. 26th at 8 A.M., and found, he had just recovered ,from a fainting attack. The general condition was much the same as on the 24th, but the pulsewas 90 and rather easily compressed ; the temperature was 100° and the respiration 20 ; the pupils were sluggish and nystagmus was present. I ascribed his condition to straining during the passage of a hardened stool. He was conscious, but occasionally rambled. On taking the temperature about threequarters cof an hour later it had risen over a degree. There was muscular twitching. I attempted to make a diagnosis of "concussion by succussion." On Dec. 27th the patient was. in a semi-comatose condition, the urine was voided at long intervals, and the bowels moved involuntarily. The pnli:ewas 80 and the temperature 102°. He bad delirium of a, low muttering form. On the 28th his condition remained unchanged. The urine was examined and was found to bo free from sugar and albumen. On the 29th he was less. delirious, but the twitching continued. The temperature was 101°. The patient was still very drowsy. On the 30th he appeared better. The pulse was fairly good as regards volume and compressibility, and he was less drowsy. The temperature was 100°. On the 31st his condition was the same as on the previous day. The temperature was 98.8° and the pulse 85. He was conscious and resting well. The natural functions were performed consciously, and he had not rambled since the day before. On Jan. 1st the temperature was normal and the pulse regular-80. The twitching and nystagmus had ceased. He spoke rationally and expressed himself as feeling better. On the 2nd there was no change. On the 3rd he had severe convulsion and suddenly became On Jan. 4th he died. At the necropsy, cncomatose. cortex.) Jan. 8th, there was no external injury or post-mortem stainThe inaction of the intercostals in respiration proper-since ing. The body was well nourished. A transverse incisionI thought it owing to a very limited myelitis or other local was made from ear to ear, and a longitudinal incision along the lateral of morbid change of some part of horns, if not the spines of the vertebræ, the skin and fascia were reflected tc more of the cord-makes me surmise, as has been already expose the muscles of the neck. The trapezius was normal, said, that in ordinary cases of croupous pneumonia, cases and reflected. The splenius and sterno-mastoid were normal. with discoverable local pulmonary disease, there is a very local The splenius was divided and reflected. The complexus was central morbid change, if not of the lateral horns, as I sup- normal. There was no injury to any of the muscles. The pose there was in Mr. Wilkin’s patient, yet of some other cervical spine was cleaned ; there was no lesion. The external parts of a cord district of which that tract is part. It may ligaments appeared normal. The spinal column was opened at any rate be worth while to search the cord and medulla from the second to the ninth vertebrae. The cellular tissue microscopically of one who has died of pneumonia. We between the medullary sheath and the ligaments lining themust bear in mind that Mott thinks that the intermediospinal column were deeply stained with extravasated blood. lateral tract is the visceral column. In later notes I shall The blood was extravasated in the subarachnold space. reconsider the case of Mr. Wilkin’s patient and suggest other There was a laminated diffuse clot in the portion correpossibilities. sponding to the second, third, and fourth cervical vertebræ There was slight subaracnoid effusion along the longitudi1In a case of fracture dislocation crushing the cervical cord across On the right side there was a,. below the emergence of the phrenic nerves the chest walls do not move nal fissure of the brain. either in respiration proper or in a non-respiratory (voluntary) service. very superficial subarachnoid clot overlapping the frontal as

I

compressed,