galar adventitial neuritis, that any swelling of accessible nerves can be distinguished.

Reflex action from the skin varies much in its condition. In cases with hyperesthesia it is often increased, even when there is considerable motor palsy; the muscles that escape cause the movement, and the impression that reaches the reflex centre is doubtless increased in degree just as is that part of it which reaches the brain and is felt as increased sensation. But in severe cases, with extensive loss of power and sensation, the skin-reflex may be lost. The loss may be observed to coincide with an increase in the other symptoms, and generally to be related to loss of sensibility to touch with extensive inotor palsy; it may, however, be lost when sensation is perfect. Occasionally it is lost out of proportion to the other symptoms, motor or sensory. The muscle-reflex action (myotatic irritability), as we have already seen, is almost invariably lost. Although the knee-jerk has been observed to persist in rare cases (Déjerine), its persistence is quite exceptional, and probably depends on the escape of at least some of the fibres on which the action depends. Possibly, however, the knee-jerk is sometimes excessive in the early stages of the disease in consequence of an irritable state of the nerves on which it depends, similar to that which gives rise to the hyperesthesia. I have more than once found it increased in cases of slight sensory neuritis (e. g. with symmetrical tingling and slight anesthesia on the soles), and in one such case it disappeared as the disease progressed. On the other hand, it is often lost when there is scarcely any appreciable weakness of the extensors, although usually some tenderness of these muscles suggests an affection of the afferent path.

Trophic changes occur in prolonged cases-in the nails, skin, and hairs, and are similar to those of ordinary neuritis; glossy skin, arthritic adhesions, and thickening being the most common. Bedsores are not common- -a fact well established, but not altogether easy to explain. The vaso-motor nerves may present disturbance of function, and some œdema of the limbs is common, especially in cases that are due to alcohol: the blood-state or impaired function of the kidneys probably aids in its production. It occurs about the ankles, back of the foot, and very frequently about the wrist and back of the hand. In one very severe and fatal alcoholic case the legs and back were the seat of a peculiar brawny edema, pitting very slowly, and attended with lividity of the skin in the depending parts, which became brighter in colour on pressure. In this case endocarditis developed during the course of the malady. In one recorded case œdema was present only over the nerve-trunks in the neighbourhood of joints-a place in which the movement of the limbs especially disturbs the sheath-nerves of the trunks, to which the vaso-motor nerves of the part are probably related. Indeed, it is common for adema to be present about the joints when it is not elsewhere, and this may be the explanation. Pain in the joints and even some

effusion into them have been observed, especially in association with au acute onset, but it is perhaps more often gouty* than rheumatic in alcoholic cases, and its significance as to the "rheumatic" nature of the neuritis must be looked on with some suspicion. It may be occasionally a result of the disease of the nerves, since chronic changes in the joints often take place just as they do, in the inflammation of single nerves. It is especially common in the finger-joints and in the wrist, but it occurs also in the shoulder and knee, less frequently in the elbow and other joints of the legs. There is pain on movement and thickening about the joint, with ultimate limitation of movement. It is a troublesome effect of the disease, because it interferes with movement when power returns. There is much more tendency to it in some cases than in others, and it may be so extensive as permanently to cripple the sufferer. The adhesions commonly re-form after they have been forcibly broken down.

The symptoms are wide-spread in proportion to the acuteness and intensity of the malady, but differ in these respects also according to its cause. The effect of metallic poisons is usually limited and confined to the arms, as in lead palsy. In alcoholism all the limbs are often affected, but the arms escape more often than the legs. From malaria the legs usually suffer alone; such cases are considered at p. 151. In cases with complex causation a general parenchymatous neuritis may be accompanied by a be accompanied by a preponderant adventitial inflammation of some one nerve, as the facial or sciatic. The cases with most widely distributed symptoms are those that result from obscure toxæmic states, from cold, and from alcoholism. It is in these, and especially in the first, that the nerves of the heart, larynx, and of the muscles of respiration most frequently suffer. When the laryngeal nerves suffer it is usual for both adduction and abduction of the vocal cords to be weakened, seldom one movement only. The optic nerves have been affected only in rare cases with considerable bloodchange. In the case mentioned on p. 126 (in which there was brawny oedema and endocarditis) there was slight optic neuritis and a diffuse oedematous retinitis. The face has also been affected on both sides in some of the cases due to exposure to cold, and also, usually in slight degree, in some toxæmic cases; it seems always to escape in cases due simply to alcohol. The sphincters almost always escape; a slight impairment of function has indeed been met with in a few very severe cases of probably pure polyneuritis, but their affection, as already stated, usually indicates an implication of the spinal cord.

The Course of the affection is determined by the same conditions as influence its intensity, and by the extent to which the cause is under control. The more severe and acute the symptoms, the

Acute gout, it must be remembered, sometimes attacks the larger joints with or before the smaller ones, and may closely resemble an attack of rheumatic fever. ✦ As in a case recorded by Taylor, Guy's Hosp. Rep.,' 1888.

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The changes are described by Edmunds and Lawford, Trans. Oph. Soc.,' ix, 137.

wider is their range and the longer is their duration. Very commonly the symptoms increase during three to six weeks, then become stationary (if the cause is stopped), and after one or two months slowly improve. The first sign of improvement is a diminution in the pain and hyperesthesia, but the tenderness of the muscles and the nerve-pains on movement often continue long after the spontaneous pains have ceased. If tingling, &c., ceased as the disease advanced their return may herald improvement. Power slowly returns, first in the muscles affected last and least, and afterwards in those paralysed and wasted in greater degree. In these the weakness lasts for many months, and shortening of the opponents of the most affected muscles is apt to occur. The contracture of the calf muscles, secondary to palsy of the flexors of the ankle, constitutes a grave hindrance to the use of the legs in standing and walking. The patient cannot get the sole and heel on the ground so as to afford a uniform base of support, and keep his body upright so as to balance it. But this contracture invariably yields to persistent efforts to walk. The palsy of the arms lasts longer than that of the legs, or vice versa, according as the one or other suffers most. The excess of impairment of the muscles most affected is often very conspicuous during recovery. Improvement goes on for a long time, generally until recovery is perfect, but very rarely there is some permanent loss of power. It is remarkable, however, how almost complete a recovery may take place, even after the paralysis has been considerable for a year. The wasting lessens and power returns; latest where there is most loss of irritability, and usually later in the small muscles of the hand than in the muscles of the forearm. Relapses are apt to occur, but only when the cause of the neuritis is still in operation in some degree, or when the patient is again exposed to it or to some adjuvant cause, such as cold.

But the malady sometimes runs a very acute course, especially in the cases due to toxæmia or to cold, so that all parts of the limbs have become weak and the extremities powerless by the end of seven or ten days, and the involvement of the nerves of the respiratory muscles may bring life to an end within a fortnight, sometimes even within a week. In this form there may be severe initial pain, not specially related to the regions afterwards affected. In one case it was severe in the back, in another across the abdomen. It is probably a direct effect of the blood-state, distinct from its influence on the peripheral nerves. Such cases bear considerable resemblance to those of acute ascending paralysis" in their course-differing, however, in the fact that the ascension is up the limbs rather than up the general frame. Sometimes, on the other hand, the disease presents a course far more chronic than that described above, and occupies many mouths in its development and progress. This is often the case with the limited alcoholic forms, especially the ataxic variety, "pseudotabes," and with cases in which the toxic agent is absorbed from with

out very slowly and its effect accumulates gradually, as in some cases of chronic arsenical poisoning. Slight cases, again, treated promptly have been known to recover in a month.

The temperature, usually raised in an acute onset (see p. 120), may be normal in chronic cases, with or without an occasional rise, or may be slightly raised during the chief part of the course of the disease. A persistent considerable elevation suggests some complication, such as phthisis, and should lead to careful and repeated examination of the lungs. It may also indicate a persistence of toxæmia, other indications of which are mentioned among the complications of the disease.

The Cause of Death in acute cases is often palsy of the respiratory muscles, sometimes aided by a catarrhal bronchitis, or paralysis of the heart when the vagus is affected; in more chronic cases it may be caused by exhaustion, due to chronic gastric derangement and the wearying effects of prolonged suffering, or the effects of disease of the spinal cord. Pneumonia frequently causes death in the acute forms, and in alcoholic subjects the inflammation of the lung so often runs a low course, with extensive consolidation, sometimes bilateral and unusual in seat (as in the middle lobe and central portions of the lung), that it is difficult to avoid the suspicion that its form and course are determined by coincident neuritis of the pulmonary branches of the vagus, either primary or secondary to the inflammation of the lung. Death may result unexpectedly from cardiac failure when no preceding symptoms have suggested an affection of the cardiac nerves, and in such cases there is generally a coincident degeneration of the walls of the heart. Fatal neuritis of the vagus, however, may occur very early in relapses. Other coincident effects of chronic alcoholism are frequent causes of a fatal issue, such as cirrhosis of the liver, gastric troubles, and chronic cerebral meningitis in cases of alcoholism, or acetonæmia in cases of diabetic polyneuritis. Various morbid blood-states, causing the neuritis, may continue and cause death. Lastly, phthisis is a frequent cause of death, and probably varies in the relation it bears to the neuritis, sometimes being its consequence, and sometimes apparently a coincident effect of some obscure cause. COMPLICATIONS.-The chief of these have been just enumerated in the list of the causes of death. The most important in alcoholic cases are the effects of alcohol on various organs and tissues, especially on the liver, heart, and spinal cord. It is very common to find the liver enlarged, sometimes very large; less commonly it is contracted. The enlarged liver may be either fatty or fibroid. Ascites and other effects of portal obstruction are much less frequent complications than might be expected, perhaps because it is rare to have much contraction of the new tissue in the liver. The kidneys also are often diseased. Gastric catarrh with its varied symptoms, morning vomiting, anorexia, and the like, is very common. So also are the several effects of gout due to the alcoholism or to metallic poisons when these have

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been the cause of the neuritis (as lead, or, as in one case under my notice, silver). On the part of the nervous system there may be various subacute and chronic forms of inflammation of the substance of the spinal cord or of its membranes, the common manifestations of which are to a large extent prevented by the affection of the nerves. The most important, the trunk girdle pains and the affection of the sphincters, are further considered in the section on diagnosis. Chronic cerebral meningitis is also common, and usually fails to produce its usual manifestation, pain, even when marked and extensive opacity and increase of fluid are found after death. It usually causes some chronic mental disturbance, often slight optic neuritis, and sometimes general convulsions. But mental change is also common as a direct effect of the alcohol on the brain; distinct delirium tremens often coincides with the onset of the neuritis. In most alcoholic cases, indeed, the mental state is unnatural; the patient is irritable, intolerant of pain, and deficient in self-control. Various manifestations of hysteria occur in women, and a peculiar childish jocularity is sufficiently common to deserve special mention. The craving for withheld stimulants increases the irritability, and, in the case of women, previous training in duplicity in order to obtain alcohol has usually induced a general deterioration of the moral sense, which has results that startle those who have been successfully deceived. Mental change is for the most part absent in the cases due to cold (save in some in which there is an intense bloodchange), and in those produced by metallic poisoning; but it occurs frequently in toxæmic cases, generally in the form of simple delirium, and is apparently due to a simultaneous action of the morbid agent in the cells of the brain. A persistent morbid blood-state may cause endocarditis and other consequences.

Phthisis is also a very frequent complication; its double relation to the neuritis has been already mentioned. The form of lung disease met with in neuritis presents no special peculiarities, except that low pneumonic changes play a considerable part in the morbid process. Acute pneumonia is also common.

PATHOLOGICAL ANATOMY.-The changes in the nerves correspond to those already described in the account of neuritis, with the exception that the chief changes of isolated neuritis are in the connective tissue, and especially in the sheath; and those in the nerve-fibres are subordinate. In most cases of polyneuritis the connective tissue suffers far less than do the nerve fibres. Considerable variations are found, however, in the extent to which the two elements suffer. In rare cases, and chiefly in those in which the distribution of the affection is not strictly symmetrical, the inflammation chiefly affects the sheath and interstitial tissue; in acute symmetrical cases both the connective tissue and nerve fibres are involved, as in Fig. 59, p. 132. This was also the condition in the case of fatal septicæmic neuritis recorded by Roth (see p. 115). In the vast majority the fibres are affected chiefly