the selected cases mentioned I am sure that the advantages claimed for it will be realized. A score of cases in my practice attests its value.

LOUISVILLE.

PROGRESSIVE MUSCULAR ATROPHY BEGINNING IN THE LEGS.*

BY J. B. MARVIN, M. D. Professor Principles and Practice of Medicine and Clinical Medicine in the Kentucky School of Medicine.

Progressive muscular atrophy is one of the most chronic and incurable of all spinal affections. Typical forms of the disease commencing in the upper extremities, causing gradual wasting, usually of the small muscles of the hand, independent of local lesion or primary functional inactivity, are comparatively common, and are readily recognized by any one making any pretense to skill in diagnosis. The clinical picture of the disease being well-known, there is no crying necessity for cumbering the literature of the subject with the details of a case of the usual typical variety, and I would not presume to tax your patience with such a recital. The case I wish to report belongs to the irregular and rare form of the disease, and presents some features of interest. March 25, 1886, Mr. W. M., of Young's Creek, Ind., was referred to me by my friend, Dr. John Sloan, of New Albany, Ind.

Mr. M. is twenty-eight years old, white, a native of Indiana, strongly-built, florid complexion, six feet high, weight one hundred and sixty-nine pounds. He was born and reared on a farm; was healthy as a child and youth; is free from inherited diseases, is temperate, and has not "wasted his substance in eating, drinking, and riotous living." Both parents are living, and healthy; has a number of healthy brothers and sisters. No member of his family has any nervous disease or is affected as himself, as far as he knows. He has no recollection of ever being sick until he was about twenty years old, when he had flux, which was prevailing in the community; during the summer of the same year, after a hard day's work, plowing, in the hot sun, he was overcome by the heat, was confined to his bed for several days, suffered with nausea, vomit*Read before the Kentucky State Medical Society, June, 1886.

ing, and fever. Loss of appetite, a feeling of exhaustion, and general weakness prevented him from doing his accustomed farm-work for two or three weeks. There were no special head symptoms or loss of power in the extremities. There was no time during this attack when he could not stand or walk. Some time after this, he can not fix date, he noticed awkwardness in his legs, especially when he tried to run or jump. This gradually increased, and he lost the "spring of his feet," and found it difficult to raise his heels and stand on his toes. He never experienced any pain or abnormal sensation in his back or legs. He no-" ticed the calves of his legs were very small; he can not tell when the wasting of these muscles began, nor in which leg the wasting started, or whether it appeared simultaneously in both legs. He continued his farm-work until about two years ago, when he noticed he was more easily fatigued, and work caused a weak, tired sensation in the lumbar region and in his legs. He consulted a physician, and quit work for four months, when, not experiencing any benefit, he ceased treatment and returned to his work.

Last summer he worked in the harvest field. He says it aggravated all his symptoms. His hands are tremulous when tired, excited, or embarrassed, and at these times he can not write easily or smoothly. More recently he has noticed quiverings in the muscles of the thighs and hands, and occasionally has cramps in his fingers. He easily looses his balance, and stands with his feet apart, or one foot in advance of the other. He never has headache or vertigo. He can preserve his balance best when barefooted, or standing on a soft or yielding surface. On examination, I find no head symptoms whatever. Pupils are normal; he has a habit of squinting the right eye, and there is a slight occasional contraction of the orbicularis. His hands and arms are well developed; he is not conscious of the slightest loss of power or atrophy in them. When his arms are extended the hands become slightly tremulous, and slight fibrillary twitchings are seen in the muscles between the thumb and first finger of the right hand; also marked fibrillary contractions about the shoulders,

are slightly rounded. All the muscles of the upper extremities respond to the faradic current, and there is no apparent atrophy or loss of power. The interossei act well. The legs are very small, measuring, just above the ankles, 8 inches, at largest part of leg, 10 inches, just above the knee, 13 inches. The legs have lost their proper contour, are flattened posteriorly; the calf muscles of each leg are symmetrically atrophied en masse, the skin closely applied to the muscles. There are no fibrillary contractions below the knees. There are no sensory or trophic disturbances; no bladder, bowel, or sexual symptoms. The temperature of the legs is slightly lowered; and the patient has noticed increased sensitiveness to cold. The legs and feet perspire freely; the feet are held at right angles to the the legs; the patient can not raise his heels and depress his toes. The plantar reflex is diminished. The patellar reflex is well marked, stronger on the right than on the left leg. The gastrocnemii and soleii give but the faintest suspicion of a response to the faradic current; there is no "reaction of degeneration," the anterior leg muscles and the intrinsic muscles of the feet respond to the faradic current more feebly than normal. Fibrillary contractions are marked in the thigh muscles and gluteal region, muscular contractility is exaggerated, tapping the tendon of the quadriceps causes widely diffused contractions of the thigh muscles, the thigh muscles respond normally to electricity. When the patient stands with his heels together, the thigh muscles become rigid, and there is a marked depression on each side anteriorly over the insertion of the gluteus maximus. The patient is sway-backed; fibrillary twitching and slight atrophy are detected in the lumbar muscles. The patient has some difficulty in walking up steps. His gait is peculiar-the so-called loosely strung gait; ankle motion more defective than knee or hip action; the joints have never been painful, nor are they enlarged.

Progressive muscular atrophy, beginning in the lower extremities, is very rare. Duchenne saw it only twice in 159 cases; Roberts, five

times in 62 cases; Friedreich, twenty-seven times in 146 cases.

When this rare form of the disease does occur, it differs from the typical form in that whole muscles or groups of muscles, rather than individual fibers and parts of muscles, undergo atrophy. While the possible occurrence of this irregular form is generally admitted, recent authorities claim that most of these cases are not examples of true progressive atrophy. Eulenberg thinks this form occurs only in children, in a form allied to pseudo-hypertrophic paralysis.

Erb separates the juvenile hereditary forms. from true progressive muscular atrophy, "they differ from it in localization and course, anatomical changes and clinical phenomena in the muscles, and alterations in the spinal cord." Bramwell and others claim that many of these cases are identical with chronic anterior poliomyelitis. From the history of this case, as detailed above, I do not think any one could claim it as an instance of pseudo-hypertrophic paralysis. Chronic anterior poliomyelitis, with which progressive muscular atrophy is most frequently confounded, is characterized by gradual motor paralysis, with subsequent rapid atrophy, abolished reflexes, reaction of degeneration: the muscles of the legs are first paralyzed, then those of the thigh and hip, and then in turn the upper extremities are involved, the extensor muscles of the fingers being first affected. The disease runs a comparatively rapid course, and generally terminates favora bly. In the majority of cases improvement occurs after a stationary period, the paralysis and atrophy disappearing more or less completely, the muscles last affected being the first to recover. Though my case has many ures in common with this description, I can not persuade myself that it belongs under this head. The absence of distinct paralysis, the loss of motor power following atrophy and directly in proportion to the muscular wasting, the reflexes being retained, no reaction of degeneration, persistent fibrillary contractions, and the extremely slow yet onward progress of the disease seem fatal to a diagnosis of chronic anterior poliomyelitis. It only remains to say a few words concerning the so-called juvenile

feat

progressive muscular atrophy of Erb. As described by this author, "There is slow, symmetrical but intermittent, and often stationary wasting and weakness of certain groups of muscles, preferably those encircling the shoulder and upper arm, the pelvis and upper thigh and back, an atrophy which is very frequently combined with true or false muscular hypertrophy, with a peculiar toughness of the atrophying muscles, but without fibrillary contractions or any trace of the reaction of degeneration or other lesion in the body, be it of the nervous system, organs of sense, vegetative organs, or external integuments." The disease begins in youth or childhood, and agrees in its symptomatology and in the anatomico-histological alterations of the muscles with pseudohypertrophic paralysis. The disease is eminently hereditary, not "infrequently it occurs in entire groups in one family, producing the so-called hereditary-better named, familymuscular atrophy." "If this form occurs after puberty it affects most frequently, although not exclusively, the upper half of the body."

The absence of heredity, the late development, and its long confinement to the legs, with eventual involvement of certain muscles of the thighs, lumbar region, and upper extremities with marked fibrillary contractions, seems to exclude my case from this category and justify the diagnosis of progressive muscular atrophy.

LOUISVILLE.

MEDICAL CURE OF GLAUCOMA.-M. Panas recently submitted to the Paris Academy of Medicine a communication on the treatment of certain forms of glaucoma without operation. In the view of M. Panas, the myotics hitherto employed as palliatives may also play the roll of curative agents; but to obtain favorable results their use ought to be prolonged. They should, in preference, be employed in the form of collyria. The two formulas usually employed by M. Panas are a solution of one twenty-sixth of a grain of sulphate of eserine to the dram of water, or one twelfth of a grain of nitrate of pilocarpine.

The collyrium of eserine is always to be placed in the first rank. From Le Progrès Medical.

Societies.

KENTUCKY STATE MEDICAL SOCIETY. Thirty-first Annual Session, held at Winchester, Ky., June 23, 24, and 25, 1886.

The meeting was called to order by the President, J. P. Thomas, M. D., of Pembroke. The minutes were read, and also the reports of the Committee on Credentials, the Committee of Arrangements, the Librarian, Secretary, and Treasurer. The Secretary reported $241, less expenses, leaving a remainder of $183.60. The report on Necrology included the names of Drs. R. W. Dunlap and A. R. McKee, both of Danville.

The President then made the annual address, taking for his theme, "The best Doctor for the Commonwealth, or the Doctor as an Officer of the State." The scope of his theme would necessitate extensive allusion to "a higher medical education," the discussion of which had hitherto produced but poor results in this State, though others have in this respect been more successful.

"It had been said that 'to be great in medicine one must be familiar with all its collateral branches;' but the field is now too broad, embracing as it does the vast range of science, together with philosophy as exhibited in various systems of evolution. Yet a certain acquaintance with these matters is requisite to a right understanding of the nature of disease processes."

Nor would the speaker have the embryo doctor waste his time in the study of the classics. A good English education, however, should be rigidly required. There are in the ranks of the profession so many ignorant doctors that, were Malthus living, he could not but set down the increase of quackery and oversupply of uneducated doctors as one of the most effective checks on increase of population. The main fault is not with the colleges, but with the material sent them. Competition compels the colleges to admit all who apply.

A great error on the part of those who oppose legislative control of medical practice is the assumption that legislative action is sought only in behalf of a limited class of

physicians and for their selfish interests, when the chief object is the protection of the people.

It is not quite certain that complete control, under our system of government with its political methods, can be accomplished, but the great success of enactments to that end in Alabama, Virginia, and North Carolina, are suggestive and encouraging.

The physician is an officer of the State, liable to be called on to give his opinion in cases involving medico-legal questions. When once laws are passed securing to the government the services of those who are competent they are never repealed.

In France one so great as Pasteur can not practice the simplest medical or surgical office because he has not taken the doctor's degree. In our country the gravest operations can be undertaken by the most ignorant.

The State should secure for itself the best medical officers, and encourage them to become sanitarians.

It is some comfort to know that our legislature did, after much persuasion, pass a law authorizing a board of health. But for the objects to be accomplished the appropriation is altogether inadequate. And it was only justice to say that the distinguished Secretary had accomplished more intelligent and beneficial work in his department, and with less compensation, than any other officer in the service of the State.

With Dr. Bowditch, he believed that the development of sanitary science is the great work of the future.

In conclusion, he recommended that a committee of five or more members be appointed to draft a bill covering the necessary legislation for accomplishing the objects considered in the address, the necessary expense to be paid out of the funds of the association; and congratulated the Society on having two of the opposite sex enrolled as members. The address has already been published in pamphlet form and will be widely read.

ULCERATION OF THE SIGMOID FLEXURE OF THE COLON.

Dr. J. G. Carpenter, of Stanford, reported a case of ulceration of the sigmoid flexure of the

colon. It occurred as the sequel of dysentery. The patient was a male, aged twenty, American, good family history and constitution. Case seven months in duration. Dr. C. elevated the trunk seventy or eighty degrees, retracted the anus with a Sims' speculum, and inflated the bowel; used at different times sunlight, lamp-light, and the electric lamp and laryngoscopic mirror. He could see within the bowel twelve inches by measurement. To cleanse the bowel he used water as hot as could be borne. The reporter found that Sims had reported a similar case in Bryant's Surgery. This hot water was used twice daily for cleansing and antiphlogistic purposes. Nitrate of silver was applied every six to eight days, of a strength of forty to sixty grains per ounce.

Dr. Pinckney Thompson, of Henderson, Ky., thought the claims of the reporter almost impossible.

Dr. W. H. Wathen, of Louisville, thought it could be done.

Dr. William Bailey, of Louisville, thought the reporter had been "able to see farther into the subject" than any one else.

REPORT ON OPHTHALMOLOGY.

Dr. Martin F. Coomes read the report on Ophthalmology. Hypermetropia, myopia, and astigmatism were mentioned as the chief optical defects giving rise to headaches. Asthenopia was also considered to be a frequent exciting cause. A disease resembling glaucoma in many respects was also described as producing severe headaches.

Dr. J. M. Ray, of Louisville, said that he had seen a case with Dr. C., in which all of the symptoms of glaucoma were present, save the "stony, hard globe." The eye could not be examined with an ophthalmoscope on account of its extreme sensitiveness, hence the condition of the disk could not be determined. By the persistent use of eserine locally, and by the liberal use of wine and good diet, the patient made a perfect recovery.

In answer to a question from Dr. Reynolds, he said he was inclined to think it was glaucoma, but the patient would not let the eye be touched. Has often seen eserine relieve the symptoms of acute glaucoma. It will relieve the pain and

lessen the tension in a short time in certain cases. An operation, however, should be done if a cure is expected. Has seen the sight in glaucoma simplex kept up for years by the use of half a grain to the ounce solution of eserine. This was proven by the sight diminishing when the drug was temporarily discontinued.

Dr. Williams, of Cincinnati, had had much experience in glaucoma. Many practitioners do not know glaucoma. They think it neuralgia, and give quinine. Or they take it for cataract, and say, let it alone and have it operated when it gets ripe; but there is no use operating on a ripe glaucoma. General practitioners ought to know more of glaucoma. He had found eserine helpful, but has never seen a case of confirmed cure from it. But it does good as a means of diagnosis, deciding whether operation should be done. If there is improvement under its use it is a good indication.

Dr. Reynolds is satisfied that eserine never exercises any favorable influence; glaucoma is an affection of the periphery; if the limitation of the field of vision is absent after the use of eserine, it is evidence that glaucoma is absent. Considers the examination of Dr. R.'s case incomplete. Eserine does relieve pain and tension.

Dr. Ray has seen several cases of glaucoma in which tension was reduced by eserine; had seen one case where the glaucoma returned and was a second time relieved; had seen several where the glaucoma disappeared.

Dr. Yandell, in behalf of the general practitioner, would ask if glaucoma is influenced at all in its exacerbations. The questions are, should glaucoma be treated by any other means than operation; whether eserine is not a delu sion and a snare? In the opinion of ophthalmologists of very large experience it is clearly not worthy to be trusted.

EVENING SESSION.

THE UNCOMMONNESS OF COMMON POLITENESS.

Dr. E. Williams, of Cincinnati, read one of his customary witty papers on this subject. "Why," the speaker asked, "is politeness like smallpox and scarlet fever? Because it is contagious. Non-contagious politeness is malig

nant. Like common sense, common politeness is a scarce thing in the market." The address was received with laughter, applause, and a vote of thanks.

REPORT ON PATHOLOGY.

Dr. D. S. Reynolds, of Louisville, made the report on Pathology. In considering this new science, which we call pathology, he wished to instill a sort of skepticism which rejects as facts every thing which can not be clearly demonstrated. "I stand here to affirm," he said," that tuberculosis is an infectious and contagious disease, disputed by no one who has undertaken experimental investigations." Heredity, he thought, had nothing to do with it. He reported cases where he had found tuberculous bacilli in catarrh of the nose and ear. He reported also his examination of water from typhoid-fever wells in Louisville, and exhibited microscopical specimens. In typhoid fever there are two kinds of micro-organisms; one that produces the mild forms, and the other the malignant forms of the fever.

Dr. F. C. Wilson, of Louisville, thought heredity had much to do with the production of tuberculosis. He thought many cases could could be traced to contact.

Dr. Pinckney Thompson, of Henderson, thought that the specific cause of typhoid fever had not been discovered. In the city it is quite impossible to find a case which can not be traced to some other cause than that named by Dr. Wilson. In the country he had seen typhoid fever exist where it was impossible to have come from another case.

Dr. William Bailey, of Louisville, regarded some of the statements made in the paper as overpositive. To him the germ theory is the most plausible one. Most theories must, as yet, be held sub judice. He thinks we can not dismiss heredity with a wave of the hand, and is sure that we can not make the insurance companies dismiss heredity from their questions.

Dr. J. T. Whittaker, of Cincinnati, said that in discussing the acquisition or heredity of tuberculosis, we should inquire, Is there not more than one element in this disease? Disease requires not only seed but soil. We