ditions, the results being given in tabular form as well as in the text. Frequent references are made to the results of other investigators, with which Condulmer and Bordon agree in most instances. The impression is given that the work would have been more valuable had more frequent observations been made in each case, only one or two being recorded in the majority of cases.

Studio Clinico statistico sui morti per paralisi generale progressiva nel R. Manicomio di Torino nel decinnio 1894-1903. Dei GUISEPPE MarGARIA. Annali di Freniatria, Vol. XVI, p. 177, Giugno, 1906.

The author has made a statistical study of the cases of paresis treated at the Royal Asylum at Turin during ten years, and from this study derives the following conclusions:

I. The age of incidence of paresis varies from 20 to 70 and more years. The greatest number occur in the period between 41 and 45 years (20.8 per cent) and in wider limits, 35 to 50 years (56.7 per cent).

2. Paresis occurs in greater frequency in man than in woman, the ratio being 1 to 3.6.

3. The social condition influences the etiology of the disease a little. It was found that it occurred more frequently in dwellers of cities than in those of the country. Of the former 83.8 per cent and of the latter 16.2 per cent.

4. Heredity as a single cause was found in 2.97 per cent, and associated with other causes in 30 per cent.

5. Alcoholism was the single cause in 27.87 per cent, with syphilis next in 11.40 per cent; while these two causes together in 8.37 per cent hold the third place.

6. The duration of paresis, independent of sex, age of development, and of cause, varies between wide limits, up to 10 years. The greater number die in from one to two years.

7. The most frequent cause of death is marasmus (38.81 per cent); 48.18 per cent die from chronic affections directly due to the paresis; 18.41 per cent from ictus and 13.5 per cent from acute affections not connected with the general disease.

8. The age and the cause of the disease has little or no influence on the cause of death.

W. R. D.

The Mental Disorders of Pregnancy and the Puerperal Period. By NATHAN RAW. Edinburgh Medical Journal, Vol. XX, p. 118, August, 1906. This article, the author states at the outset, is based on his observations of 102 cases of mental troubles coming on during the period of pregnancy or in the puerperium. His cases were first seen in his own wards of a general hospital, but the lunacy law only allows the detention of the patient for a short period (the exact time being three weeks), on the

expiration of which time the patients were transferred to the County Asylums. For this reason the writer is unable to state how many cases were discharged recovered, but of the 102 cases, 24 cases in the three weeks had so far recovered that it was unnecessary to have them committed, the treatment being continued and concluded in a general hospital.

The author gives a short table showing the yearly admissions—those transferred to asylums-those cured and those who died. There were eight deaths from exhaustion due either to severe maniacal excitement or from the inanition accompanying the profound depression. At autopsy in four of these cases nothing could be found to account for such marked mental disturbance.

The author's first clinical observation was the large number in whom albuminuria was present, 62 per cent, the persistence of this symptom being variable. The author mentions that Sir James Simpson made this observation as far back as 1857, and that very little further knowledge into the nature of the condition has been gained.

Of the author's cases, 71 showed excitement and 31 depression, and he adds further, that those showing excitement, although their symptoms were more acute, made quicker recoveries.

The rarity of the development of a psychosis during pregnancy is next touched on. Only six out of the author's 102 cases developed at this time: they occurred between the third and seventh months. That there is a "psychological sensitiveness" in these cases that in all probability predisposes to a mental disturbance the author believes to be true and supports this by mentioning various affect anomalies present in women at this time, such as irritability, undue instability, etc., and occasionally perversion of the special senses.

That illegitimacy is a factor in the causation of these cases, the writer has not been able to prove. Clouston's view that abortion may be induced before the fourth month in cases where a psychosis develops early in pregnancy is mentioned, but the author has never had to resort to it.

Therapeutic measures suggested in these cases are, stimulating diet, special attention to the renal functions with a view to obviating albuminuria, careful nursing, and constant supervision.

The prognosis in most cases is favorable and there is an early recovery, although eight per cent of cases die and the likelihood of a fatal termination is greater than in any of the other acute psychoses.

The question of having to certify these patients naturally arises, and the author thinks it unfortunate that a woman who is suffering only from temporary alienation should have to be sent to an asylum and have to endure the social stigma that this entails. He therefore advocates the establishment of reception hospitals for acute cases, where the patient could remain for a reasonable period without being declared a lunatic, but later be removed to an asylum, if necessary.

FITZGERALD.

The Significance of Jacksonian Epilepsy in Focal Diagnosis with Some Discussion of the Site and Nature of the Lesions and Disorders Causing this Form of Spasm. By CHARLES K. MILLS. Boston Medical and Surgical Journal, Vol. CLIV, p. 453, April 26, 1906.

In this article the author first states that he uses the term broadly, meaning a mono- or hemi-spasm due to cortical or subcortical discharge presenting usually an initial symptom and a serial order of phenomena. Just here it is noted that although in many cases there is irritation or instability of motor areas of the cortex cerebri in cases of Jacksonian spasm, it is not true that there is always a gross lesion present.

That hemi-epilepsy is not always similar in character to a Jacksonian seizure should be remembered: first, because a hemi-epilepsy following hemiplegia may begin on the paralyzed side but later become general, and in children or in older individuals where there has been softening from thrombosis and subsequent destruction of tissue about the lesion, the focus which has undergone necrosis may be surrounded by greatly engorged vessels, and there may be also punctiform hæmorrhages-these being sufficient to set up convulsive seizures, perhaps at first unilateral. In such cases, of course, the mechanism is the same as in Jacksonian epilepsy, but in certain cases of hemi-epilepsy the irritative lesion may be distant from the cortex or due to a toxic state.

The author then notes that Jacksonian seizures have often had decided value in aiding the surgeon to localize the seat of the lesion in cases of cerebral tumor. Case histories are cited in which this was true and where an operation was done. All cases were due to neoplasms except one, which was caused by a localized pachmeningitis and gumma of the cortex. The other evidences of gross lesion in addition to spasm were monoplegia or hemi-paresis with exaggerated reflexes on the side in which the spasm occurred. Jacksonian epilepsy being of so much local diagnostic importance it is well to keep in mind the seat and nature of various lesions producing the condition. (1) They may be due to tumors situated in other parts of the brain than the motor cortex. (2) They may be due to lesions other than tumors situated in the motor cortex. (3) They may be due to a toxic condition and in certain conditions where no focal lesion can be demonstrated. (4) A spasm simulating the Jacksonian seizure may be observed as a reflex or hysterical disorder, and lastly, a Jacksonian fit may be an integral part of the entire expression of a case of so-called idiopathic epilepsy.

Jacksonian epilepsy from the first cause would only be possible where the causation due to the presence of a neoplasm would be of sufficient intensity to spread to the motor area—such cases are rare, and of course should not be confounded with cases in which the spasm is a symptom clearly indicating that a neoplasm has entered the motor zone where psychic speech and graphic disorders had much earlier been noted. In the author's experience tumors growing backwards from the frontal region are much more likely to cause spasm than those arising in the

parietal region and advancing toward the motor area, and it is suggested that possibly the destruction, first of sensory cortex and sub-cortex before evolvement of motor cortex or projection fibers may give immunity from such spasm.

An interesting case reported by Weisenberg is mentioned, where the tumor sprang from the eighth nerve, causing one-sided deafness, tinnitus, facial monospasm, hypesthesia of one side of the face, nystagmoid movements, slight paresis of the right abducens, vasomotor and cardiac disturbances, severe headache, nausea, vomiting, and optic neuritis. In this case the spasm was always one-sided. Another case is recorded where the tumor was situated in the cerebello-pontine angle, causing considerable difficulty in focal diagnosis, where a most successful result followed operation.

Tumors of the cerebellum and pons have also caused Jacksonian seizures.

That a spasm may be due to irritation of the dura from the presence of a tumor anywhere within the cranial cavity, must not be forgotten. This has been proven by clinical and pathologic observations, also physiologically. A point of distinction between cortical Jacksonian spasm and the convulsive seizure, due to irritation of the dura, is that the spasm will begin on the side of the irritation and rapidly spread to both sides, but the observation that the spasm is at first unilateral may not be made if the individual is not seen early in the attack. Cases in which tumors arise from adherent dura and pia in the motor area often give rise to confusing pictures of more or less generalized convulsions. Other lesions than tumors that may give rise to Jacksonian spasm are not considered, and just here it is to be remembered that even when one has to deal with a neoplasm, intense headache and optic neuritis may be absent, and nausea and vomiting not conspicuous symptoms. Depressed fractures, localized meningitis, meningeal or cortical hæmorrhage, focal hæmorrhagic encephalitis, and focal necrosis occurring from embolism or thrombosis (including cases associated with general arterio-sclerosis) may all cause seizures closely similating those produced by a tumor growth. In the case of fracture it could only happen with an old depressed fracture of the inner table of which only after a considerable time resulted in the development of Jacksonian attacks. Here operative interference would, of course, be of benefit.

Localized meningitis perhaps association with gummatous inflammation of syphilitic origin, may be benefited by anti-luetic treatment, but operative interference may also be demanded.

Jacksonian spasm due to supra- or sub-dural hæmorrhage can usually be recognized by characteristic phenomena of dural hemorrhage such as contralateral paralysis, dilated pupil on the side of the lesion, and changes in pulse, temperature, and respiration. Superficial cortical hæmorrhage, such as one finds in cases of sinus and venous thrombosis, may cause trouble if a clear history of acute or subacute onset is not obtainable. A

rare cortical condition, focal hæmorrhagic encephalitis, may in its early stages be confused with a tumor of the motor region causing Jacksonian seizures. Arterio-sclerosis is a form of focal cortical disease that must ever be kept in mind when one considers using operative interference for the relief of symptoms like those present when a neoplasm is developing in the motor area, particularly in cases where Jacksonian epilepsy is present. The cardinal points of differentiation are that in arterio-sclerotic conditions there are present the cardiac and renal changes, gradual cerebral failure, progressive loss of power on one side, and impairment or loss of different forms of sensibility, perhaps with some agraphic or aphasic disturbance, the seizures are usually slowly and irregularly developed, being fully developed late, and coming with one-sided paresis or paralysis, the history of the development of the seizures, the presence of renal, cardiac, and general arterial changes, and the absence of general symptoms of brain tumor will aid in the diagnosis. Of course, arterio-sclerosis and brain tumor may occur together, and this must not be overlooked. That operative interference has been decided on and carried out in cases where all the symptoms could have been accounted for by changes due to an arterio-sclerotic condition, is noted, although in neither case recorded was true Jacksonian epilepsy present.

In another group of cases a tumor may be present where there are also vascular lesions in other locations than that of the tumor. In such cases if there is a focus of necrosis false localizing signs may be present, which may give rise to considerable difficulty.

That hemi-epilepsy or Jacksonian seizures of smaller range may occur in toxic or diathetic conditions, such as diabetes, Bright's, uræmia, occasionally in Korsakoff's syndrome, or as an acute alcoholic manifestation, in fact, in any form of toxic or infectious disease, of course, the diagnosis from cerebral tumors in the motor area is usually not difficult.

The dural epilepsies mentioned above are reflex, the tumor irritating the dura stimulates sensory branches of the fifth nerve, setting up very severe convulsive attacks. Rarely a peripheral irritation may cause a Jacksonian seizure; in such cases it is probable that there is an unusual instability of the motor cortex, either inherited or acquired. Hysteroepilepsy is to be differentiated by the presence of stigmata.

Cases of idopathic epilepsy where the only manifestation is a Jacksonian seizure are, of course, extremely difficult to diagnose, and such cases are recorded.

It is the opinion of the author that Hughlings Jackson's observation that almost every case of idiopathic epilepsy, if studied carefully enough, will be found to have had local spasm as the irritating phenomenon of the general attack, can usually be verified, and he quotes several cases supporting this opinion.

Two cases are next recorded where an osteoplastic operation was done, but no tumor growth could be seen, and it is thought that in the first of these the condition was idiopathic epilepsy, closely resembling brain tumor