There was a soft blowing double mitral murmur to be heard, otherwise the circulatory system presented no changes. Respiratory system normal. Tongue coated and fissured. Teeth good, no line on gums. Appetite ravenous, and stools, which were occasionally passed involuntarily, normal. Genitals normal. Urine contained small quantities of albumin. Head well shaped and large; countenance blank and heavy. Speech thick, tremulous and scanning in type. There was inability to pronounce the usual tests. Marked tremor of lips and tongue. Gestures few, appropriate, made with a tremulous, jerky motion. Movements more or less incoordinated. In walking there was noticeable lack of power in the left side, making the gait a sort of sidelong shuffle. He complained of pain in the back of his thighs, dull and aching. The grip of the left hand much weaker than of the right. General sensibility slowed, but no apparent areas of perverted sensation, hyperæsthesia or anæsthesia. Patellar reflexes much increased. Ankle clonus and muscle jerk at the knee were easily elicited.

As the disease progressed from the origin as above, he grew weaker and more irritable and forgetful; would wander away and become lost. He had hallucination of hearing, especially in the early part of the night. There was no clear history and no evidence presented while in the asylum of the presence of delusions of expansive nature. Before admission to the insane department, while in the nervous wards of Blockley, there was on several occasions nocturnal delirium, and he became maniacal. It is said that at this time he had several delusions, imagining the patient in the adjacent bed a female and desiring co-habitation. He used to deck himself gaudily, sewing brass and gilded official buttons on his clothes to satisfy a whim of vanity. Was more or less restless, but quiet and nondestructive. In the insane department he recognized his surroundings, but did not demur in the least. His mental condition was not one of perversion, but rather a gradually increasing dementia, without the usual symptoms of mania or melancholia preceding. The seizures, which attacked him more or less frequently, were preceded invariably by an aura, but not by the usual epileptic cry. There was no frothing at the mouth, nor any of the spasmodic movements of epilepsy. There was always venous stasis and each fit was followed by a transient left-sided palsy. He continued in the same manner, growing gradually weaker, losing power over all his sphincters, voluntary motion becoming progressively more incoordinated until in April of the following year, when he died in one of the epileptiform paroxyms.

On post-mortem examination the following notes were made as to the cranial and cerebral conditions :

Skull-cap of about the usual thickness. No adhesions between its under surface and the dura. This membrane was markedly thickened, with strong adhesions from its under surface to the membrane beneath. The entire convexity of the brain was of a leaden hue from opacity of the pia mater, which was thickened, especially on either side of the longitudinal fissure, where it was adherent throughout its length from surface to corpus callosum. Upon the under surface of the brain similar opacity and thickening of the pia. About a pint of clear subarachnoidal fluid was obtained on entering the cranial cavity, and

both lateral ventricles were found immensely distended with the same. The entire frontal lobes were much flattened, the brain substance having shrunken fully an inch away from the dura. No gross lesions in the ventricles beyond some venous distension; no lesions found in the basal ganglia or the interior of the brain, the medulla, pons or cerebellum. The brain tissue

was soft and the cortical matter distictly narrowed.

CASE III.-General paralysis of the insane, probably of syphilitic origin.—S. H. G., colored, male, aged thirty-seven years, married, a laborer, was admitted to the insane department, at Blockley, from the county prison of Philadelphia. Nothing could be ascertained as to his family history. A year prior to his admission to Blockley, he had been under observation at the county prison and was then mildly deranged. He was a tall negro, of light brown color, with thick, black and coarsely curling hair, with black eyes and closely contracted pupils that responded only slowly to light. Ears normal, hearing apparently unchanged. Head of normal size and good shape; features were intelligent, bright and well cut. The skin of the face was thick and slightly bound; and here and there over the face, back, and the rest of his body there were syphilitic rupial sores and scars of former sores. Pulmonary examination was negative. The arteries at the wrist were tense and atheromatous; and there was diagnosed a condition of mitral insufficiency. Digestive symptoms were absent at the time of admission. His urine indicated considerable disease of the kidneys. The penis was badly eroded at the glands from the specific sores, the upper part of the gland being entirely eaten away. Near the base of the penis were several large elevated ulcers with hard raised edges.

The speech was thick, and delivery explosive upon beginning to speak, but the usual delivery had a sing-song tone. There was some tremulousness in the delivery, and a tremor was perceptible of the lips during speech and of the tongue when protruded. Motions generally were tremulous; the gait was accomplished with the feet wide spread. The power of grasping was notably diminished in both hands. There were no abnormalities of sensibility. The patellar reflexes were heightened, especially the right; no ankle clonus. The man was in poor state of nutrition. While in prison it was stated that he had had a number of “spasms,” in which he would lie apparently senseless, motionless, and without marked rigidity. After one of these he would be stupid for several days. The present attack as already stated had existed a year or more. When in prison the year previous he had made a number of very silly speeches, had been frequently somewhat dis connected in his conversation, and had been accounted a confirmed kleptomaniac. Upon admission to the asylum, in addition to the physical evidences of paresis of the insane, the patient presented marked delusions of grandeur. In spite of his physical condition he stoutly maintained a feeling of bien-etre. His countenance wore a constant smile of approval and self-esteem; and he made overtures of friendship to whomsoever he met. His sleep was frequently broken and he was awake early and late, busy with numberless plans. He was very restless, could not remain seated for any length of time. Was constantly tearing his clothes in the endeavor to better his covering. His conversation was disjointed, sometimes quite incoherent. He was on account of his health and habits confined more or less to his room; but his confinement did not seem in the least an inconvenience. It, with every other trial, was not regarded in the least in the midst of his visions of wealth and

splendor. There was a history of hallucinations of hearing while in prison, but no evidence of their continuance after admission to Blockley. While in prison he made an attempt to hang himself; and in attempting to escape he attacked a warden violently. He was peaceful and quiet, however, in the asylum; clean in his habits, but destructive of small articles about him. He was very loquacious, boasting continually of his physical prowess and of his magnificent wealth, promising all his acquaintances splendid presents. His intellectual powers all were grossly at fault; his memory was poor for both recent and remote events. His emotions were poorly controlled, joy, grief and anger being often in quick succession aroused without the least apparent cause. He did not recognize his surroundings, his position or condition in life.

He continued in such condition for about two weeks, when, having been placed by his attendant thoughtlessly into a freshly scrubbed room for several hours, an acute nephritis was superadded to his previous renal complications. Uræmia set in the day following, and after varying symptoms he died in about a week more.

On post-mortem examination practically identical appearances of the brain were noted; a considerable degree of pachymeningitis, non-hemorrhagic in character. Pia mater was thickened and opaque, especially along either margin of the longitudinal fissure and along the Sylvian fissures. Considerable ædema of the membranes was noted, as well as ventricular effusion. The convolutions were markedly flattened, the sulci shallow, and on section the cortical substance shrunken. The pia in the areas along the longitudinal fissures was adherent to the cerebral substance. Microscopical examinations of portions of these areas and of other parts of the cortex suggested the specific character of the inflammatory changes, marked by thickening of the vascular walls;. the sclerosis of the cortex was apparently most fully marked immediately around penetrating vessels.

ERYSIPELAS OF THE EYELIDS SPREADING EXTENSIVELY TO FACE AND SCALP. ORBITAL CELLULITIS. RECOVERY WITHOUT IMPAIRMENT OF VISION.

BY G. E. DE SCHWEINITZ, M.D.

FREQUENTLY the eyelids are involved in an erysipelatous attack by an invasion of the disease which has originated in the neighboring facial area; more rarely the inflammation begins in the tissues of the lids themselves. The chief interest which attaches to facial erysipelas from the ophthalmological standpoint is the blindness which has followed the attack in a number of cases, in all of which, according to Knapp,' orbital cellulitis was a complicating symptom.

The following case of severe facial erysipelas, beginning in the eyelids and probably associated with orbital cellulitis, and yet without any disturbance of vision or decided changes in the eyegrounds, includes several points of interest.

Charles Dolan, aged twenty-seven, an American by birth, was admitted to the wards of the Philadelphia Hospital, January 24, 1890. His father died at the age of forty-two, of phthisis; his mother from the effects of an abdominal operation; one brother is living and healthy. The patient is single, and with the exception of rheumatism contracted several years ago, has been free from any severe illness during his entire life. There was no history of injury. He acknowledged gonorrhea, but denied syphilis. His occupation was a street car driver, and there was no other relation of his work to his illness than the necessary exposure which such an occupation entailed. He used tobacco moderately and also alcohol. There were no sexual excesses. Six weeks before admission, the patient began to complain of severe general headache, most marked in the temples, and aggravated by moving the head and eyes from side to side. One week later diplopia appeared; according to his statement the heads of the horses were doubled and stood side by side. The muscles of the left eye were apparently those affected, inasmuch as he always closed this eye in order to avoid the effects of the double vision. There was at this time no swelling of the face and no appearance of external inflammation about the 1Archives of Ophthalmology, Vol. XIII, 1884.

eyes.

He continued his occupation and succeeded in driving correctly by keeping the left eye closed. Two weeks before he sought admission, the headaches became so severe that he was unable to continue his work, and sometime during the night of Tuesday, January 23, after hours of most intense suffering, his eyelids began to close and by morning were swollen tight shut.

Condition on admission.-The skin of the forehead was oedematous, both eyes closed, the lids swollen, bulged forward, and of a dark-red erysipelatous color. No conjunctival discharge, but the bulbar conjunctiva chemotic. The eyes moved with difficulty and pressure produced pain, the cornea was clear, and several superficial abscesses appeared in the skin of the left eyelid, which, together with the face on that side, was more swollen, especially over the antrum and down on the neck, than similar areas upon the opposite side. The tissues over the nose and between the eyes were puffed up and boggy, giving the man a typical "frog-face" appearance. There was no fluctuation at any point over the swollen surface. There

were no carious teeth and no disease of the naso-pharynx. The tongue was heavily coated, the appetite impaired, the bowels constipated. The lungs were free from râles, the respiration 20 per minute. The heart was regular in its beat, pulse 72, and no increase in arterial tension. The general intelligence was perfect, the sleep being broken only by the intense headache which had never ceased since its original onset. The pupils reacted to light. The vision, as far as it was possible to obtain this, appeared to be unaffected. The swelling of the conjunctival tissues was so great, however, that no complete ophthalmoscopic examination was possible. The urine was of a reddish-yellow color, had a specific gravity of 1018, acid in reaction, free from albumin and sugar, and contained a small sediment composed of leucocytes