(say) in the hand, and be strictly confined to a limited range, and yet the lesion apparently causing them be found at the autopsy to involve very different localities in different cases. It is true that we are told not to state that there is convulsion of a certain group of muscles, but that there is "the sudden development of certain co-ordinations of these muscles," and this is a line of inquiry which, while more difficult, promises more exactitude of result-the line of inquiry as to the localities for the leading representation of the most special movements in which each part engages.† But in the case of G. H- this physiological localisation could not be effected; many centres being implicated, one could not learn the particular order in which the movements evolved were represented in specific portions of the nervous tissue.+ A minor point is, that in some, at least, of the fits when the pupils widened the right one was the more dilated, and several times it was noticed that the right side of the occipitofrontalis was mainly in action; and that, of the chest and abdomen, the muscles of the right side were those mainly or solely convulsed. Dr. Russell has recorded a case of "hemiplegic epilepsy" in which, with right unilateral convulsions, the only muscles of the trunk implicated were the right rectus abdominis, and right pectorales.§ Now Dr. Jackson describes the spasm in this group of cases as affecting primarily the unilateral muscles of the side in which it begins, and in the next degree as passing on thence to involve also the bilateral muscles of both sides. || The case I have described is rather opposed to this view, so far as it goes. Indeed, in a later paper, he writes with some doubt on this point in referring to cases of unilateral convulsions originating in like manner as occurred in G. H.'s case-convulsions depending on "discharge" of convolutions in the region of the middle cerebral artery, and near to the motor tract.** 5.-Hemiplegia.-In range the paralysis was dextral hemiplegic. The distribution of the varying degrees of palsy in the different parts was similar to that of hemiplegia * Dr. H. Jackson, "Med. Times and Gaz.," Dec. 23, 1871. +"Med. Times and Gaz.," Aug. 15, 1868, p. 178. "Lancet," Feb. 1, 1873, p. 164. "British Med. Journal," June 22, 1867, p. 732, et seq. "St. Andrew's Rep.," Vol. iv., p. 166. T "West R. Rep.," Vol. iii., p. 337. **"Lancet," Feb. 1873, p. 163, and " West Rid. Reps.," Vol. iii., p. 336. of the ordinary kind. The facial and lingual muscles were, however, considerably involved. The order of recovery from the hemiplegia was that the leg regained power rapidly, the arm slowly, the face more quickly than the arm, but the incomplete right facial palsy was replaced, during the course of recovery, by a state of slight continuous spasm, which excludes the face from further consideration in this particular relation. A fortnight elapsed before the hemiplegia had quite disappeared. Of what character, then, was this temporary paralysis? Its history was that of epileptic hemiplegia-it was found for the first time after a succession of severe fits affecting the same side; there was slight amelioration whenever any remission occurred in their severity and frequency, and improvement set in steadily when these convulsive attacks ceased. Though the face was more involved than is usual in hemiplegia due to a cause whose locus is the cerebral cortex, yet the general distribution and history of the palsy, in this case, seemed to point to exhaustion of an area of the cortical cineritious neurine, following upon that excessive excitation which produced the convulsive phenomena. Thus, as Dr. Todd says, the undue exaltation of polar force which causes the fits, "induces subsequently a state of depression or exhaustion which will be most upon that side upon which there has been the greatest previous excitement." In the case of G. H. the epileptic hemiplegia, although temporary, exceeded the more usual degree and duration. "The presumption is that the degree of palsy depends on the severity of the convulsion, i.e., on the quantity of discharge. When the fit is severe, there may be hemiplegia complete in range, except perhaps for conjugated deviation of the head and eyes."+ In the above case conjugated deviation of the head and eyes occurred to some extent, and was further evidence that an extreme degree of epileptic hemiplegia had been reached. The posterior divisions of the (left) superior and middle frontal gyri were amongst the parts deeply implicated, and an abeyance of their function on the left side might be an explanation of this sign, based on Ferrier's experiments. As Dr. Bastian, however, has recently stated, "conjugated deviation" arises from lesions of various parts of the cerebrum. "Met with "Clinical Lectures on Paralysis," &c., 2nd Ed., pp. 299 and 300. occasionally with lesions in and upon the surface of either hemisphere, this sign occurs this sign occurs with greater proportional frequency as the lesion approaches the cerebral peduncle.”* Dr. Bastiant regards the temporary hemiplegias in cases of the epileptic group as due to spasm of the cerebral vessels, plus certain mere molecular changes of a recoverable kind in the nerve elements occurring in, or produced by, the fits. And this damage would be less easily recovered from where, as in G. H.'s case, there were wide-spread degenerative alterations in the minute vessels, and in the nerve elements themselves. Here was found no central lesion, and none of the basal ganglia, to which one might refer the paralysis. A comparison of the temperatures observed on the two sides of the body would also incline one to the belief that the lesion which produced hemiplegia was of the cerebral cortex. During the period of recurring convulsions the temperature ranged between 99.5°, and 101.7°, but on the twelfth day, when the fits had ceased, the temperature was only 97.1. On comparing the heat at the two axilla on the first day the paralysed side was found to have a temperature ⚫1° lower than the other; by the sixth day its temperature was 6° higher, and on the seventh and twelfth only 1° higher. These notes accord with Bastian's statement that in hemiplegia from lesion of the cerebral cortex the difference in temperature between the paralysed and the sound side seldom exceeds .1° Fah., and tends to disappear soon.‡ Baillarger,§ indeed, explained the transient hemiplegias occurring in general paralysis after epileptiform or apoplectiform attacks on the theory of sudden congestions which mainly implicated one of the hemispheres. The persistent hemiplegias sometimes found were, he thought, due to atrophy of the brain on the opposite side, the result either of these repeated unilateral cerebral congestions occurring during the fits, or of a confirmed unilateral congestion of gradual origin. In the case of G. H. the hemisphere opposite to the side temporarily paralysed was undergoing atrophy; its weight was 64 grammes less than that of the other side, whereas Baillarger only speaks of an inequality of from 20 to 62 grammes;|| the cerebral hyperæmia and the * "Lancet," June 20, 1874, p. 863. + "Lancet," April 25, and June 20, 1874, pp. 577 and 861. "Lancet," Nov. 7, p. 1874, 650. "Annales Médico-Psychologiques," 1858, p. 168. Baume cites cases of greater disequilibrium, "Ann. Med. Psych.," 1862, p. 541. pathological changes in the membranes were more developed on that side, and were associated with a greater degree of cortical degeneration. Had the hemiplegia been permanent in this case it would have seemed to corroborate (quantum valeat) the views of Baillarger ;* but as has been seen, the motor defect was comparatively transient, and, apparently, was due to a condition of the nervous tissue, the same as, or analagous to, that present in epileptic hemiplegia. 6.-Speech. The disorder or absence of speech may have been at first partly of the nature of epileptic aphasia, which is said to occur most frequently in those cases of unilateral convulsions in which the spasm begins at the right side of the mouth or tongue, or both.† When the speechlessness cleared away a variety of aphasiat still remained, and as this latter persisted throughout the rest of the patient's life, although for a considerable period he was free from fits, and without a trace of hemiplegia, there is every probability that it was due to those pathological changes in the cerebral cortex found over a wide area, not only in, but also on every side of, the left third frontal convolution. CLINICAL NOTES AND CASES. Lesion of Coordination in the Secondarily Automatic or Acquired Functions of Reading and Writing, with Hints of Hemiplegia. Question of Tabes Dorsalis, or Incipient Locomotor Ataxy: Clot in Right Optic Thalamus? By George ShearER, M.D. Liverpool. R. T., æt. 42. Government Ship Surveyor, of active habits, and invariable good health, educated, intelligent, humorous, and possessing considerable mental activity. He is a heavy smoker and accustomed to his beer, but strictly temperate. While in London, some five years since, he was one of a small band * Baillarger makes a clear distinction between the two varieties. He does not, as one of his critics seems to imply, attribute all the hemiplegias in General Paralytics with these modes of onset to unilateral cerebral atrophy. "L'atrophie prédominante trouve donc son explication dans ces congestions plus ou moins répétées sur l'un des hémispheres Les auteurs en effet ont admis deux sortes de congestions dans la paralysie générale, les unes lentes et permanentes, les autres brusques et instantanées Les congestions qui précèdent la paralysie générale ou qui souviennent daus son cours sont souvent accompagnées d'hemiplegies passageres En se repetant sur un seul hémisphere ces congestions finissent par amener des hemiplegies persistantes le plus souvent incompletes."-Op. Cit., pp. 172 and 173. +"Med. Times and Gazette," Dec. 23, 1871. "Bateman on Aphasia," p. 104, et seq. of fast friends of the same social standing, but differing in political and religious creeds, who used to meet every Saturday evening at each other's houses, to discuss political and religious questions, in which he always took the liveliest interest. He was constituted "Dean of the Chapter," and when he left for Liverpool, engaged to keep up weekly communication with the club by letter, on subjects under discussion. This he did for a year and a half. At the end of this period, in the month of June, 1870, he complained one day of great weariness, and had to lean against a wall for support for a few seconds. Next day, in writing out his customary weekly argument for the debating club, he felt a most extraordinary sensation-afraid to go on writing—a feeling of distraction which obliged him to desist in spite of himself. He "knocked off" for half an hour, forgot the trouble, began again, but write he could not. He got up early the next morning to finish the composition, but when he had got about half-way down the first page, he came to a word (he believes it was the word "weather ") which he could not finish, nor write another word any more than he could fly. It was a fine morning in June, and the sun was shining gloriously into the lobby of his house, so he got up, walked up and down for a while, and forgot the whole thing. At 8 a.m. he sat down again to write, but all in vain. With this attempt came on the most awful sense of some unknown terror, a sensation of something going— giving way in his brain, as if a handful of brains had been taken out of the back of his head, but without pain, or sense of weight, or heat, tension or pressure, and with perfect consciousness throughout. He ran up stairs, tore about the house, but still this awful sense of something coming on, as if he were going to have a fit, continued for some time, notwithstanding that everything was done to calm and sooth and re-assure him. The same dreadful feeling returned whenever he continued writing beyond a very few minutes at a time, and he can only compare it to that of a man standing upon a trap door which he is conscious may give away any moment, or to that of a man ready to be hung standing under the drop. The feeling of helplessness (in writing) returned so frequently that he was obliged to give up his employment for a period of three months, yet circumstances obliged him to remain in town, though he believes that complete rest from business, together with the bracing influences of the country, would, at that time, have quite restored him. Even now he can write twice as long on the Mondays after the rest of Sunday. In connexion with his official duties, he has frequently to sign his name, and at first he was so helpless in the matter of writing, that if the table were heaped with gold and silver and offered him for merely signing his name, he could not have done it. For a long time he was obliged to make his mark. After a time he found he could sign his name with his eyes shut, and in time he learned to write with one eye open, and at length, with both eyes open for a period never exceeding fifteen or twenty minutes at a time. The ability to write crept back |