Special Notices.

CHRONIC GOUTY AFFECTIONS.-In cases of chronic gout, a remedy is generally required which is adapted for long-continued administration in order to obtain any lasting improvement. Most of the drugs recommended have the disagreeable feature of disturbing the digestive organs after being taken for some time or of exciting the aversion of the patient. Lycetol is entirely free from these disadvantages. It has an extremely pleasant taste, is always well tolerated, and has proven a most efficient antiarthritic remedy. Its action in cases of gout is not only to render the uric acid circulating in the blood more soluble, but to promote its excretion by way of the kidneys, owing to its marked diuretic effect. It thus fulfills completely the desiderata of a remedy for aiding in the elimination of the materies morbi of gout, and when administered in connection with appropriate dietetic and hygienic regulations, very favorable results from its use may be anticipated.

INSTRUCTIVE EXHIBITS.-"One of the chief attractions at the annual gatherings of The American Medical Association is always the exhibition hall, where the principal drug, instrument, and food products of the world, the results of years of experimental research and labor, are placed in view.

"Among the many attractive exhibits at this year's Denver meeting, that of Imperial Granum, recognized by many leading physicians as the standard among prepared foods, occupied a prominent space, and the representative in charge was kept busy explaining to the visiting physicians the superiority of this preparation. Handsome sample boxes of the food and copies of The Imperial Granum Co.'s valuable clinical record were presented to each physician in attendance."-From The Journal of the American Medical Association, Chicago.

SANMETTO IN URETHRAL AND BLADder DiseasES-IN PRE-SENILITY AND ENLARGED PROSTATE.-In nearly thirty years' practice I have never written to the proprietors of any medicine extolling its virtues, but after some years' constant use of Sanmetto I can but say it is my sheet anchor in all urethral and bladder diseases. In pre-senility it has no equal. Have recently used it in two cases of enlarged prostate with marked benefit in both cases.

BERKELEY SPRINGS, W. Va.

GEORGE E. GILPIN, M. D.

LABOR SAVING: The American Medical Publishers' Association is prepared to furnish carefully revised lists, set by the Mergenthaler Linotype Machine, as follows: List No. I contains the name and address of all reputable advertisers in the United States who use medical and pharmaceutical publications, including many new customers just entering the field. In book form, 50 cents.

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List No. 2 is furnished in gummed sheets, for use on your mailer, and will be found a great convenience in sending out reprints and exchanges. If you do not use a mailing machine, these lists can readily be cut apart and applied as quickly as postage stamps, insuring accuracy in delivery and saving your office help valuable time.

These lists are furnished free of charge to members of the Association. Address CHARLES WOOD FASSETT, Secretary, cor. Sixth and Charles streets, St. Joseph, Mo.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

BULBAR PARALYSIS, DUCHENNE'S DISEASE, AND OTHER LESIONS OF THE BULB.*

BY H. A. COTTELL, M. D.

Professor of Physiology, Histology, and Clinical Diseases of the Nervous System in the University of Louisville.

The object of this paper is to present for discussion a report of three cases of bulbar disease. One (perhaps two) is of that form known as Duchenne's disease or glosso-labio-laryngeal paralysis. I will preface the report with a few words upon the pathology and natural history of this disease. Of course I can say nothing new upon the theme.

Duchenne's disease was recognized by Robinson in 1825, but it was first made a matter of careful clinical study by Duchenne, who made an analysis of thirteen cases in 1861. The lesions were located on theoretical grounds in the medulla oblongata by Baerwinkel, Schultz, and Wachsmuth, and later the correctness of these theories was confirmed by autopsies made by Charcot, Joffroy, Leyden, and many others.

Symptoms. According to Gray and Dana, the symptoms are as follows: Vague pain in the neck and back of the head, slight vertigo, a sense of contraction about the chest and breast, and occasional dyspnea. Loss of reflex excitability in the pharynx, larynx, trachea, and esophagus has been noted. But tactile sensibility was maintained. Paralysis, and atrophy of the tongue, lips, lower part of the face, palate, and finally the larynx and heart are the chief visible signs of the disease.

*Read before the Louisville Medico-Chirurgical Society, September 23, 1898. For discussion see p. 309.

It has been questioned whether the atrophy or the paralysis was first to develop. But in the majority of cases the former preceded the latter. The condition of the tongue is usually first to attract the patient's attention. There is slight difficulty of speech. The tongue is then found atrophied. It is often agitated by minute fibrillary tremor. Pronunciation is impeded. First difficulty is found in pronouncing the letter i, then r, st, s, 1, k, g, t, and lastly d and n. Morsels of food can not be swept around the mouth with the usual facility, and deglutition may be interfered with.

Muscles of the lip and lower face are affected, first orbicularis oris, then levators of upper lip, the quadratus menti, the triangularis menti, the levator menti, and the buccinnator. Eyelids are rarely affected; but Landon Carter Gray has seen two cases in which there was paresis of the upper lids.

Saliva dribbles from the mouth. The lips become so paralyzed that the mouth can not be shut. "The upper face wears an expression of anxiety and suffering. Articulation becomes almost entirely lost; the voice has a nasal twang from paralysis of the palate." (Dana.)

"The patient has tired and uncomfortable sensations of dryness and stiffness about the throat. There is no pain or anesthesia; but occasionally there is impairment of the sense of taste. The throat reflex is usually lost, so that tickling it causes no reaction." Electric irritability is at first unchanged, but in the later stages partial degenerative reaction occurs. In rare cases there is rapid pulse, and more rarely glycosuria.

"The laryngeal reflex becomes weak, the adductors also, but adductor paralysis is rare. The mind is not affected, but there is often emotional weakness."

"The disease is often the terminal stage of a spinal muscular atrophy; it may be associated with the latter, with amyotrophic lateral sclerosis, or with ophthalmoplegia. All these types may occur together." (Dana.)

Anatomy and Physiology. The anatomical importance of the medulla oblongata can hardly be overstated when we remember that it is not only the avenue through which nearly all afferent and efferent impulses travel from periphery to center and from center to pheriphery, but that the nuclei, or centers of origin, of eight of the twelve pairs of cranial nerves are situated in it. There are also twelve centers presiding over important functions, and at least three of these are vital:

Respiratory, cardio-inhibitory, cardio-acceleratory, and perhaps that of deglutition. Also, "it should not be forgotten that in the medulla are the centers for the special senses, hearing and taste, and that other special centers are supposed to be localized there, of which may be mentioned one, the hypothetical inhibitory heat center, which controls the production of heat by the tissues independently of the vaso-motor center." (Dana.) Kirker, Hand-book, 1896, Wood, p. 580.

"The third and fourth cranial nerves arise from gray matter beneath the corporaquadrigemina; and the roots of origin of the remainder of the cranial nerves can be traced to gray matter in the floor of the fourth ventricle, and in the more central part of the medulla, around its central canal, as low down as the decussation of the pyramids.” Ibid, p. 581.

The nerve nuclei involved in Duchenne's disease are, as its admirable name, glosso-labio-laryngeal paralysis, indicates, that of the twelfth (hypoglossal), the seventh (facial), the tenth (pneumogastric), the eleventh (spinal accessory), and the ninth (glosso-pharyngeal). The last, however, being a sensory nerve, can not take part in the motor paralytic symptoms of the disease. And for the same reason the pneumogastric (tenth nerve) may be excluded, although it is the carrier of important motor branches to the larynx and pharynx which are involved in the paralysis. When we remember that the nucleus of the seventh nerve may be and probably is connected with the nucleus of the twelfth or hypoglossal nerve, and that the nuclei of the ninth, tenth, and bulbar nucleus of the eleventh can not be anatomically separated, while the nucleus of the twelfth (hypoglossal) is very long and lies adjacent to and to the inner side of the combined nuclei of the ninth, tenth, and eleventh nerves, we may easily understand the symptoms of Duchenne's disease and differentiate it from other lesions in the bulb.

Pathology. The disease is due to “degenerative changes in motorganglion cells of the bulb, similar in kind, and homologous in site, with those which, when occurring in the spinal cord, give rise to progressive muscular atrophy." (Bastian.) The character of the lesion is thought by some to be inflammatory; by others more correctly, degenerative. In fact, the disease is sometimes complicated with lateral sclerosis, and the atrophic process is found to be similar to that observed in the spinal disease. (Dana.)

The evidences of muscular degeneration are marked. "The muscles of the tongue and to a less extent the orbicularis oris and throat

muscles show evidences of degeneration and atrophy. In some cases the tongue is not shrivelled, owing to the presence of a fatty deposit, and on account of this the disease has been divided into atrophic and paralytic types, but this distinction is not necessary." (Dana.)

Diagnosis. "The disease must be distinguished from acute polioencephalitis inferior [an extension of polio-myelitis from the cord into the medulla], bulbar apoplexy, tumors, and softening from multiple sclerosis and from chronic lesions of the cerebral hemispheres, causing pseudo bulbar paralysis. It must also be distinguished from asthenic bulbar palsy. The slow onset, the progressive course, the bilateral character, the absence of involvement of sensory nerves, and the degenerative reactions are sufficient for a diagnosis. In asthenic bulbar palsy there is great paralysis, but none of the typical atrophy of the parts. It is always important to note whether there are ophthalmoplegia (polio-encephalitis superior) and spinal muscular atrophy associated with the disease." (Dana.)

Prognosis. The disease "runs a progressive course, with remission of a few weeks or months. It lasts from one to three or four years. In one case (Dana's) it has lasted seven years." The termination is eventually fatal. Death occurs through interference with swallowing, and inanition, or a broncho-pneumonia, or bronchitis, may develop, which ends the patient's life.

Treatment. Rest, high nutrition, and massage and electricity are recommended by the books. Electricity, twice or thrice daily, should be tried for a short time. The faradic current alternating or combined with the galvanic may be employed. Galvanization of the neck or medulla does no good.

Very small doses of morphia (25 to 3% grain) and atropia may be given. "After a time it is necessary to feed with a tube or even do a tracheotomy." (Dana.)

CASE 1. Mrs. S. G., age twenty-two; December, 1894. Symptoms: First, numbness about the right elbow. A ring sensation about elbow, just as if a rubber band was there. The ring was of large diameter. Second, about four weeks later, occipital headache, very severe, worst early in the morning. Not felt while lying in bed, but very marked on rising; after a while, on stirring around, the headache would be better; but some headache remained all day long. Headache lasted about four weeks. Whole right side had sensations of numbness. A sensation of numbness ran down inner part of thigh,